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Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine

Emergency Trauma Care – Evidence for Impact on Survival. Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine Aga Khan University, Pakistan. Workshop for Setting Regional and National Road Traffic Causality Reduction Targets in the ESCWA Region

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Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine

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  1. Emergency Trauma Care – Evidence for Impact on Survival Junaid Abdul Razzak MD PhD FACEP Associate Professor and Chairman Department of Emergency Medicine Aga Khan University, Pakistan Workshop for Setting Regional and National Road Traffic Causality Reduction Targets in the ESCWA Region 16-17June, 2009 Abu Dhabi, United Arab Emirates

  2. Outline • Why is Trauma Care Important? • Trauma Center versus Trauma System • Evidence for Effectiveness of Trauma System in Saving Lives • Conclusion

  3. Issue 1 Why is Trauma Care Important?

  4. Time and Trauma Deaths Primary Prevention Strategies Trauma Systems Trauma Systems & Rehabilitation

  5. The Probability of Survival 100 80 Survival Is Related To Severity and Duration 60 % Survival 40 20 0 30 60 90 Minutes

  6. Issue 2 Trauma care system

  7. Definitions of Terms • “Inclusive Trauma Systems” • Not just hospitals for acute care; • Care from site to hospital to home to work • “Regionalization” • Geographical Definitions • Based on Population • “Public Health Approach” • Research Based; System Wide; Multidisciplinary;

  8. Inclusive Trauma Care System Hospital and Post Hospital Phase Pre Hospital Phase

  9. Regional Trauma System • An organized and coordinated response that ensures a continuum of care at a Regional Level • Public access to the system through a uniform emergency number • Out of hospital emergency medical services (EMS) with medical control • Timely triage and transport to an appropriate level of hospital care • Reliable communication between EMS & hospital personnel • Access to trauma centers if needed • Seamless transfer to rehabilitation • The key to disaster care

  10. Issue 3 Evidence for effectiveness

  11. Do Trauma Centers Make a Difference? Skamania Conference July, 1998 A symposium to evaluate the evidence regarding the effectiveness of trauma centers and systems Journal of Trauma Sept, 1999

  12. Skamania Symposium – Conclusions • Evidence to date is fragmented • Largely based on preventable death studies conducted in local areas • A few population based studies have been conducted – using administrative data and historical controls • Existing studies have focused on hospital mortality • No data on VALUE !

  13. PERCENT OF ALL SERIOUSLY INJURED (ISS > 9) WHO DIE Percent of injured patients who expire

  14. If Care Was Equally Good.. Potential for saving hundreds of thousands of lives?

  15. Training for Pre-Hospital Care Providers and Mortality Change in Mortality of one in pre and post PHTLS changes the p value from 0.046 to 0.06 Ali et al. J Trauma 1997

  16. Training for Pre-Hospital Care Providers and Mortality The p-value become insignificant with an increase in just one death Arisa C et. Al., 2004

  17. Sukumaran S. et al. 2005

  18. Preventable Deaths Before and After San Diego Trauma System Implementation of Trauma System 1984 2009

  19. Crash Mortality Rate RatioPre/post Trauma System Implementation California Connecticut D.C. Florida Georgia Illinois Massachusetts After adjusting for change in traffic safety laws, mortality was reduced by 8% across 21 states Missouri Nevada NewJersey NewMexico NewYork NorthCarolina Oregon Pennsylvania SouthCarolina Tennessee Utah Virginia Washington WestVirginia All .5 .6 .7 .8 .9 1 1.1 1.2 1.3 1.4 1.5 1.6 Mortality rate ratio Nathens et al

  20. 1.05 1 .95 Mortality rate ratio .9 .85 .8 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Years since trauma center designation Mortality Rate Ratio As A Function Of Time From First Trauma Center Designation Benefits of regionalization were not seen until 10-15 years after trauma center designation Nathens et al

  21. Risk of Dying:25% Lower in Trauma Centers! 15 10 5 0 TCs In 30 days 90 days 365 days NTCs Hospital Overall risk of death is 25% lower in trauma centers compared to non trauma centers NEJM 2006;354:366-78

  22. Effect Larger for Young Adults . . . butLittle Effect Among Older Adults NEJM 2006;354:366-78

  23. Trauma Center Care is More Costly ! MacKenzie, Jurkovich, Rivara et al, 2009

  24. Issue 4 What does it all mean?

  25. Conclusion I Trauma SystemsNOT JUSTTrauma CentersAcross the continuum of careRight patient – Right hospital – Right time • Pre-hospital • Triage • Coordination (Security) • Communication • Transportation • Rehab

  26. CONCLUSION - II A SUCCESSFUL TRAUMA CARE SYSTEM IS DEFINED BY: Inclusiveness Regionalization of Services Organizational framework based on Public Health Model System focused on Education, Research, Data/Trauma Registry, Prevention

  27. CONCLUSION - III Current Evidence Shows that in HICs Trauma System can: • Reduce the trauma related mortality by atleast 8%; • Such reduction is seen over time and it may take upto 10 years to show its effectiveness

  28. Thank You junaid.razzak@aku.edu

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