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

1. Trauma Training: Where Do We Spend Money to Get Best Results Kris Arnold, MD, MPH, FACEP Asst Professor Emergency Medicine (retired) Boston University School of Medicine

2. Disclosures • None

3. 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.

4. Trauma Care

5. Points of Intervention to improve outcome Factors

6. The Best Bang for your Buck

7. Where/when is it happening Monterey, Mexico (n=545) 40 Mortality 21 (ISS ³9) Seattle, USA (n=533) 11 7 6 3.3 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.

8. Definitive Care Proximity No Surprise Distance to VD => Mortality Viet Duc St Paul Bach 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.

9. Not Only Road Crashes Vietnamese burned while on phone at gas station Posted on October 25, 2012 Skyscraper on fire, 11 injured in Vietnam capital Posted on October 25, 2012 Cold wave unrelenting in Northern Region Posted 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

10. Emergency Care Proximity

11. Injury Treatment LocationRural Vietnam Distance from care was also positively associated with not getting care. Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health.Vol 123. England 2009:58-65

12. Catastrophic Costs 16.9 % Household Income spent on injury care 13.2 7.4 Affordable health expenditure ≈ 5% total household income WHO defines catastrophic health care cost as ≥ 50% disposable income WHO. Designing health financing systems to reduce catastrophic health expenditure. Geneva: WHO;2005 Hang HM, Byass P. Difficulties in getting treatment for injuries in rural Vietnam. Public Health. Jan 2009;123(1):58-65.

13. Who can give care? • Event • Self/ • Bystander Self / bystander Care

14. Trauma Care in Hanoi Note total %>100 since some victims received assistance from person of more than one group Nguyen TL, Nguyen TH, Morita S, Sakamoto J. Injury and pre-hospital trauma care in Hanoi, Vietnam. Injury. Sep 2008;39(9):1026-1033.

15. Bystander Effect I am sure someone else will take care He does not really need help He will be OK He is probably drunk

16. Scene to Hospital Transport • Pre-hospital care (transport) Transport Professional Care

17. 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.

18. Improving the Picture Trinidad and Tobago Monterey, MX 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-RisaC, 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.

19. 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.

20. Truck Driver First Aid - Ghana Self-report No outcome data 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

21. In-hospital trauma care • Emergency Department Emergency Department Inpatient Care

22. 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

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

24. So What to Do

25. Physicians & Nurses 12.2 10.1 Practitioner / 10,000 population Note: Vietnam MoH reports 7 doctors/10,000 projected for 2010 World Health Organization, World Health Statistics 2012. http://www.who.int/healthinfo/EN_WHS2012_Full.pdf Ministry of Health – Five Year Health Sector Development Plan 2010-2015 http://www.wpro.who.int/health_services/viet_nam_nationalhealthplan.pdf

26. Health Resources Per 10,000 population

27. 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.

28. Relative Training Cost *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

29. The Human Factor 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. 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, 2013 http://talkvietnam.com/2012/12/district-medical-clinics-not-patronized-by-local-residents/#.UQUzAmewWSo December 18, 2012

30. Resource Upgrade *Trauma training at post graduate level = advanced specialization related to trauma or continuing education course on trauma care Son NT, Thu NH, Tu NT, Mock C. Assessment of the status of resources for essential trauma care in Hanoi and KhanhHoa, Vietnam. Injury. Sep 2007;38(9):1014-1022.

31. Level of Pre-Hospital Intervention Scoop ‘n Run vs Stay ‘n Play • 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.

32. 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

33. Mandate for the Future Prime Minister Nguyen Tan Dung HanoiJanuary 24, 2013 online meeting to review the health sector’s mission in 2012 and plans for 2013 • 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 • emphasisedthat medical ethics is connected with a sense of responsibility. Ordered the health sector to: http://talkvietnam.com/2013/01/pm-asks-health-sector-to-adopt-high-ethical-standards/#.UQUyfmewWSo

34. Aligning Sectors Mr. Luong Ngoc Khue Ministry of Health International Conference on Traffic Safety in Vietnam, November 23, 2012 • 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 traffic Posted on November 26, 2012 http://talkvietnam.com/2012/11/international-experts-examine-vietnams-traffic/#.UQVR2mewWSo

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

36. Questions

37. Cảmơn