Trauma Training: Where Do We Spend Money to Get Best Results

Kris Arnold, MD, MPH, FACEPAsst Professor Emergency Medicine (retired) Boston University School of Medicine

Disclosures

• None

Objectives

• Explore the points in the chain of trauma response and care for the most cost-effective training points for improving outcomes.

• Explore options that have been employed in other resource-constrained developing trauma response systems.

Trauma Care

Event

Self/

Bystander

Pre-hospital care

(transport)

Emergency Department

In-hospital (acute care

+ rehab)

Post-hospital

Points of Intervention to improve outcome

Phase Human Vector Environment

Pre-Event Driver EducationTask training

Vehicle design and maintenance

Highway design

Event Reaction Vehicle safety features

Road safety barriers

Post-Event Medical Response

Gas tank seal Road quality for health care access

Factors

The Best Bang for your Buck

Field ED

In P

atie

nt0

5

10

15

20

25

30

35

40

Where/when is it happening

Arreola-Risa C, Mock CN, Padilla D, Cavazos L, Maier RV, Jurkovich GJ. Trauma care systems in urban Latin America: the priorities should be prehospital and emergency room management. J Trauma. Sep 1995;39(3):457-462.

Mortality

11

40

21

3.36 7

(ISS ³9)

Seattle, USA(n=533)

Monterey, Mexico(n=545)

Definitive Care Proximity

Viet Duc

St PaulBach Mai

Nagata T, Takamori A, Kimura Y, Kimura A, Hashizume M, Nakahara S. Trauma center accessibility for road traffic injuries in Hanoi, Vietnam. J Trauma Manag Outcomes. 2011;5:11.

No Surprise Distance to VD =>

Mortality

Not Only Road Crashes

Vietnamese burned while on phone at gas stationPosted on October 25, 2012 Skyscraper on fire, 11 injured in

Vietnam capitalPosted on October 25, 2012

Cold wave unrelenting in Northern RegionPosted on January 4, 2013

Hospitals in Hanoi, like the National Hospital of Pediatrics, Bach Mai and Saint Paul, are also treating a large number of people with weather related ailments.

http://talkvietnam.com

Emergency Care Proximity

Population2011

RuralUrban

Rural69%

Urban31%

Injury Treatment Location Rural Vietnam

Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Vol 123. England 2009:58-65

Distance from care was also positively associated with not getting care.

Catastrophic Costs

WHO. Designing health financing systems to reduce catastrophic health expenditure. Geneva: WHO;2005Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Jan 2009;123(1):58-65.

Rich Poor Very Poor02468

1012141618

Affordable health expenditure ≈ 5% total household incomeWHO defines catastrophic health care cost as ≥ 50% disposable income

7.4

13.2

16.9

% Household Income spent on injury care

Who can give care?

Event

Self/

Bystander

Self / bystander Care

Pre-hospital care

(transport)

Emergency Department

In-hospital (acute care

+ rehab)

Post-hospital

Untrained Provider

None Family CompanionsPassersby

52%

33%

19%

19%

Trauma Care in Hanoi

Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):1026-1033.

Note total %>100 since some victims received assistance from person of more than one group

Bystander Effect

He does not really need

helpHe will be OK

I am sure someone

else will take care

He is probably

drunk

Pre-hospital care (transport)

Scene to Hospital Transport

Emergency Department

In-hospital (acute care

+ rehab)

Post-hospital

Event

Self/

Bystander

TransportProfessional Care

Trauma Care in Hanoi

First Aid Provider

Commune Health Worker

14%

Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):1026-1033.

Improving the Picture

Pre PHTLS Post PHTLS0

2

4

6

8

10

12

14

16

Mortality (%)

Ali J, Adam RU, Gana TJ, Williams JI. Trauma patient outcome after the Prehospital Trauma Life Support program. J Trauma. Jun 1997;42(6):1018-1021.Arreola-Risa C, Mock CN, Lojero-Wheatly L, et al. Low-cost improvements in prehospital trauma care in a Latin American city. J Trauma. Jan 2000;48(1):119-124.

Effect of Pre-Hospital Trained Intervention

• Slightly greater effect in rural areas versus urban areas

Henry JA, Reingold AL. Prehospital trauma systems reduce mortality in developing countries: a systematic review and meta-analysis. J Trauma Acute Care Surg. Jul 2012;73(1):261-268.

Untrained Trained0

20

40

60

80

100

120Mortality

- 25%

Truck Driver First Aid - Ghana

Before Training After Training0

5

10

15

20

25

30

35

40

45

Scene ManagementAirwayExt BleedingSplinting Limb

Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal emergency medical services. J Trauma. Jul 2002;53(1):90-97

Self-reportNo outcome data

In-hospital trauma care

Emergency Department

Post-hospital

Event

Self/

Bystander

Pre-hospital care

(transport)

Emergency DepartmentInpatient Care

Meeting the need

• Hanoi Health Service

• The emergency service centre and hospitals in Hanoi can meet only 3.9% of emergency needs

Hanoi Health Service. Annual Injury Prevention Report; 2006

Resource MatchingSystem Level Commune District Province/City Central

Unit CT/DL VN/TG Hanoi

CR/Vni DA/SS Hanoi

KH SP Hanoi

VDHanoi

Inpatient Beds 1 0-2 70-165 200 550 500 500

Inpatients/yr 120 200 1930 1200 3800 2000 14,000

% Trauma 10 3 48 50 23 25 50

Total Trauma 12 6 926 600 874 500 7,000

Doctors with Trauma Training*

0 0 63% 83% 25% 50% 60%

Nurses with Trauma Training*

20% 0 31% 24% 25% 25% 70%

Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9):1014-1022.

• Relatively low frequency of cases in commune/Province/City suggests may have more need for primary trauma care training due to degradation of skills with non-use

• 8,106 trauma cases/yr for Hanoi population of 6 million = 22 trauma hospitalizations/day

So What to Do

Physicians & Nurses

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

2

4

6

8

10

12

14

Physicians

Nurses

Practitioner / 10,000 population

World Health Organization, World Health Statistics 2012. http://www.who.int/healthinfo/EN_WHS2012_Full.pdfMinistry of Health – Five Year Health Sector Development Plan 2010-2015 http://www.wpro.who.int/health_services/viet_nam_nationalhealthplan.pdf

12.2

10.1

Note: Vietnam MoH reports 7 doctors/10,000 projected for 2010

Health Resources

Nurses Physicians Hospital beds0

20

40

60

80

100

120

USFranceVietnamChinaCubaCanada

Per 10,000 population

Health Care Education Cost

• Thai Binh, Bach-Thai, Hai-Phong (1997-1999)

• Total cost/medical student – 9,527 USD

• Physician training ≈ 14 X Nursing training

• First aid ??

Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4):412-420.

Relative Training Cost

Physician*Nurse*EMT**First Aid***

*Bicknell WJ, Beggs AC, Tham PV. Determining the full costs of medical education in Thai Binh, Vietnam: a generalizable model. Health Policy Plan. Dec 2001;16(4):412-420.**Relative pricing based on average of several US EMT tuition rates***Based on relative cost of American Red Cross Advanced First Aid course to cost of 4 years medical school in US

The Human Factor

District medical clinics not patronized by local residents“…shortage of good doctors and inadequate facilities”

http://talkvietnam.com/2013/01/healthcare-sector-hampered-by-poor-quality-training/#.UQUyXWewWSo January 11, 2013http://talkvietnam.com/2012/12/district-medical-clinics-not-patronized-by-local-residents/#.UQUzAmewWSo December 18, 2012

Director of the MoH’s Science and Training Department Nguyen Cong Khan said that even if the number of students who graduated from medical schools by 2020 doubled, they would still fail to meet the demands of the healthcare sector.

However, at present the rate in the Cuu Long (Mekong) Delta is 5.27/10,000 and in some provinces it is even lower, such as SocTrangProvince at 3.78/10,000 and HauGiangProvince with 4.05/10,000.

Resource Upgrade

System Level Commune District Province/City Central

Unit CT/DL VN/TG CR/Vni DA/SS KH SP VD

Doctors with Trauma Training*

0 0 63% 83% 25% 50% 60%

Nurses with Trauma Training*

20% 0 31% 24% 25% 25% 70%

Ambulances Pvt Pvt 1DH Pvt

1DH Pvt

5 5 5

Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa, Vietnam. Injury. Sep 2007;38(9):1014-1022.

*Trauma training at post graduate level = advanced specialization related to trauma or continuing education course on trauma care

Level of Pre-Hospital Intervention

• Mexico– Arreola-Risa results

• No improvement in mortality w/ ALS– Arreola-Risa C, Mock C, Herrera-Escamilla AJ, Contreras I, Vargas J. Cost-

effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Prehospital Disaster Med. Oct-Dec 2004;19(4):318-325.

• Developed countries– No advantage to ALS

• Worse mortality w GCS<9 – Stiell IG, Nesbitt LP, Pickett W, et al. OPALS Study Group. The OPALS major trauma

study: impact of advanced life-support on survival and morbidity. CMAJ. 2008;178:1141-1152.

Scoop ‘n Run vs Stay ‘n Play

Bottom Line• All sectors could use more persons trained in

organized emergency and trauma response– Continuing and upgrade education for people already

working in health care with likelihood to care for emergencies and trauma

• The use of first responders with minimal training has been shown to decrease mortality– First responder training is much less costly than

training professionals

• This all needs to be in the context of developing the protocols and infrastructure for an organized approach to emergency care – Regional EMS

Mandate for the Future

• Focus on raising quality of treatment in district hospitals across the country so as to help in reducing overloading in central hospitals.– doctors from the bigger hospitals to visit

clinics in the countryside to share their skills

• Imbibe a sense of responsibility in medical staff– emphasised that medical ethics is connected

with a sense of responsibility.

Ordered the health sector to:

Prime Minister Nguyen Tan Dung Hanoi January 24, 2013

online meeting to review the health sector’s mission in 2012 and plans for 2013

http://talkvietnam.com/2013/01/pm-asks-health-sector-to-adopt-high-ethical-standards/#.UQUyfmewWSo

Aligning Sectors

• Many traffic accident victims died because of lacking first aid.

• Traffic policemen should be trained with first aid techniques.

• First aid stations should be set up along highways.

International experts examine Vietnam’s trafficPosted on November 26, 2012 http://talkvietnam.com/2012/11/international-experts-examine-vietnams-traffic/#.UQVR2mewWSo

Mr. Luong Ngoc KhueMinistry of Health

International Conference on Traffic Safety in Vietnam, November 23, 2012

Partners

• Husum – Village medical university• Mock – Low tech interventions• Karolinska/Bavi – Epidemiological data• Japanese – Epidemiology/GIS plotting• WHO• Red Cross• Small NGOs • Universities

Questions

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