Amit Gupta
Professor, Trauma Surgery & Critical Care
Greetings from AIIMS, New Delhi
09-11-2017
JAI PRAKASH NARAIN APEX TRAUMA CENTER
AIIMS, New Delhi Estd. 2006
4 Es
Engineering of Roads
Education of People
Enforcement of Laws
Emergency Medical Services
09-11-2017
Injury Pyramid
Each Death ~ 30 Severely
Injured Patients
Will have considerable post injury
disability
Brain Injury, Spinal Injury,
Amputations
4 million
09-11-2017
Silent Genocide
40 - 45%
Transport
related
Injuries
55 - 60%
09-11-2017
09-11-2017
Care of the severely Injured
Requires a broad framework of policies and
protocols in a given geographical area
Seamless transition between each phase of care,
integrating health resources
Team work between various agencies
09-11-2017
National Trauma Policy Thrust Areas
Improvement in Health care Infrastructure at rural levels
Strengthen organizational aspect Establish Trauma Systems
Pre Hospital
Information Transfer and communications
Inter-facility Transfer
Protocol Development
TRAUMA CENTRES (26 Level I; 110 Level II; 260 Level III)
Trauma Education / Interest Generation
Pre-Hospital
Definitive Care
Rehabilitation
Evaluation and Research
09-11-2017
Pre-hospital Care
Pre Hospital Care being
given by a private agency
with a common number
108
Adopted by 19 States and is
in different phases of EMS Body to govern and Audit
No Legislation/
Commissioning Sustainability??
ALS + BLS
Short Term Trained
personnel
Communications Center
with GPS enabled systems
09-11-2017
CAPACITY BUILDING Manpower Training
Manpower training through short term courses like:
ATLS (Doctors); ATCN (Nurses)
ATAM (Advanced Trauma Assessment & Mn. Course); NTMC (National Trauma
Management Course)
PHTLS, AUTLS
Empowering Bystanders: Trauma First Responder (TFR) &
AIIMS BECC
Rural Trauma Team Development Course
Long Term Capacity building:
M.Ch. (Trauma Surg. & Critical Care)
MS (Traumatology & Surgery MCI)
DM (Trauma Intensive Care)
Various Fellowships in Spinal Trauma/ Pelvic Trauma etc.
M.Sc. (Trauma & Emergency Nursing)
09-11-2017
Other Activities
Rehabilitation Centers
4 Regional
35 State Level (One in Every State/ UT)
Activities for data collection and injury prevention
related research
National Injury Surveillance Center (RML Hospital)
Initiation of Nodal Trauma Registries Research Mode
(JPNATC/ AITSC/ ICMR)
Networking of Regional and formation National Trauma
Database
Public awareness activities for Injury Prevention
09-11-2017
Multipronged Approach
09-11-2017
TRAUMA SERVICES
Care of Injured Patient
ACUTE CARE
=
IN HOSPITAL IN HOSPITAL
DEFINITIVE
CARE
TRAUMA CENTRE
Acute Rehab.
(Physical and
Neuro)
09-11-2017
Dedicated
Trauma
Service
& Surgeons
Teaching Community
and Outreach
and
Training
Public
interest
TRAUMA
CENTER
Trauma
Quality
Research and
Performance
Improvement
Trauma
Registry
09-11-2017
TRAUMA CENTRE
IS AN
ORGANIZATIONAL CONCEPT
AND NOT AN
INFRASTRUCTURAL CONCEPT
09-11-2017
Components of Trauma System
Structure
Physical Resources
Infrastructure
Equipment and
Technology
Structure
Human
Resources
Staffing and
Training
Processes
Organization
Administration
Protocols
09-11-2017
Patient load
Emergency Department footfall
60000 56987
62308 66654 66982
52992
59158
50000 55698 47138 47104
43230
49894
40000 38217
Red
30000
Yellow
Green
20000
15672
0
2011 2012 2013 2014 2015 2016
20000
15000
10000
5000
0
2011 2012 2013 2014 2015 2016
09-11-2017
Patient load
Total Admissions
5500
5400
5408
5300 5373
5200 5254
5100
5192
5000
4900
4930
4800
4814
4700
4600
4500
2011 2012 2013 2014 2015 2016
09-11-2017
Patient load
Major Surgeries Performed Annually
7000
4000
3000
2000
1000
0
2011 2012 2013 2014 2015 2016
09-11-2017
TRAUMA CENTRE
TRAUMA
INFRASTRUCTURE
DEDICATED
Resuscitation
TRAUMA
Unit
CRITICAL CARE
Trauma ED
IN HOSPITAL IN HOSPITAL
ACUTE CARE DEFINITIVE TRAUMA NEURO
Radiology Blood CARE
Bedside X- CRITICAL CRITICAL
Ray, USG
Bank +
and CT Em. Lab. CARE CARE
Acute
Rehab.
Radiology Blood
Interventional (Physical Laboratory
Including
Radiology +/- and Neuro) Bank Medicine
Intervention
Immediate or IN PATIENT
Emergent PHYSIOTHERAPY
WARDS
Operating UNIT
NS, TS and
Room Physical, Chest and
Ortho
Neuro Rehab.
Forensic
Till patient in
Forensic
Services Trauma Center Services
09-11-2017
Trauma Emergency Department
PATIENT FLOW
4
Red Area Yellow Area Green Area
Compromised Stable ABCD Minor Injuries
ABCD with Major Injury Major Injury with stable ABCD
Architectural Triage
09-11-2017
ED Equipment
RED AREA YELLOW AREA GREEN AREA
09-11-2017
ED Manpower
RED AREA YELLOW AREA GREEN AREA
Resuscitation Protocols
According to Adv. Trauma Life Support or any other Intl. Protocols
Admission Protocols
No confusion Continuity of Care is maintained
Radiology Protocols
Right studies for the right patient
Interventional Radiology if required
Medico-legal and Transfer Protocols
09-11-2017
Trauma Definitive Care
O
T
DISCHARGE
I
C
U
DEATH
TRAUMA ED
W
a
r
d
09-11-2017
Trauma Definitive Care
09-11-2017
Trauma Critical Care Units
Trauma Surgery & Neuro-trauma
Critical Care ICU ICU
09-11-2017
Other Critical Support Departments
Basic Lab
Radiodiagnosis Blood Bank
Medicine
09-11-2017
Nursing Empowerment &
New Nursing Paradigms
Trauma Nurse Coordinators
Coordination amongst various services
Quality Control
Injury Surveillance & Registry Data
Teaching & Training
Wound Care Nursing
Dedicated wound surveillance
Wound care (Out/ In patient services)
Teaching & Training
Hospital Infection Control
Infection Surveillance and Control
Teaching and Training
Nursing Informatics
Centre-wide Computerization
New IT Solutions
IT Teaching and Training
Transplant Coordinators
09-11-2017
Teaching and Training Facilities
Seminar Room
09-11-2017
Teaching and Training
Short Term Courses
International Courses
ATLS (Advanced Trauma Life Support course)
ATCN (Advanced Trauma Care for Nurses)
AUTLS / Em-SONO (AIIMS Ultrasound Trauma Life Support)
PHTLS (Pre-Hospital Trauma Life Support)
RTTDC (Rural Trauma Team Development)
AO Spine and Pelvis Trauma Courses
Indigenous Courses
Cadaveric Courses in N Sx/ Ortho/ Trauma Sx/ Plastic Sx
Basic and Advanced Pelvic Trauma Course
AIIMS BECC
AIIMS Trauma Assessment & Management Course (ATAM)
AIIMS Trauma First Responder Course (AIIMS TFR)
Management of Acute Wounds in Emergencies (MAWE)
Personality Development and Communication Skills
09-11-2017
Teaching and Training contd..
Community TRAUMA
Outreach CENTER Research
Primary Prevention
Organ Donation
09-11-2017
DEVELOPMENT OF A HOSPITAL BASED
INJURY SURVEILLANCE
&
TRAUMA REGISTRY
AT
JPN APEX TRAUMA CENTER, AIIMS
WHERE IS THE DATA COMING FROM
MORTALITY DATA
PROJECTIONS
09-11-2017
HOSPITAL BASED DATA
NOT ONGOING
NO PROSPECTIVE OR PERMANENT DATABASE
MOST EFFORTS ADHOC PROJECTS
INJURY SURVEILLANCE
09-11-2017
CONTRIBUTIONS TO EMERGENCY
MEDICINE RESEARCH
09-11-2017
BARRIERS TO EFFICIENT TRAUMA
REGISTRY
Little or no pre-hospital care
Non-availability of evacuation and
transportation system
Limited inter-hospital communication in case
of transfers.
Lack of standardized and uniform hospital
data formats
Limited availability of electronic data storage
and retrieval facilities
09-11-2017
BARRIERS TO EFFICIENT TRAUMA
REGISTRY
Inadequate funding
09-11-2017
BASIC ELEMENTS OF TRAUMA
REGISTRY
A trauma registry uses both computer software packages and
hardware for the collection, verification, storing and analysis
of data.
Defining a Trauma Patient
Inclusion/ Exclusion Criteria
Defining the Dataset
Extensive vs Minimal
Type of Data Collected
Confidentiality of Registry data
Data Validation and Quality
Report writing
09-11-2017
APEX TRUAMA CENTER
WHO (Injury prevention group)
Multi-centric feasibility study on Injury Surveillance
To study the feasibility of injury surveillance and to identify
a model for sustained data collection, analysis and
reporting.
Retrospective Data Collection
On a data collection format finalized by the AIIMS team in
line with the prescribed WHO Injury Surveillance performa
Retrospective Data collected from Medico-legal Registers,
and Autopsy registers
Data collected from
1st Jan 2005- 30th June 2006
09-11-2017
LESSONS FROM PILOT STUDY
Hospital Injury surveillance is feasible and can
give a variety of information regarding injury
patterns in hospital patients
The retrospective study has guided us
Incorporation of more variables in the MLRs
Formulations of in-hospital injury surveillance and
registry format was developed
Point of data entry into such a performa was defined
Electronic data storage and data archiving platform
was developed
Difficulties
09-11-2017
DEVELOPMENT OF A HOSPITAL BASED
TRAUMA REGISTRY AT JPN APEX TRAUMA
CENTER
The JPNATC Trauma registry started its preliminary
data collection from April 2009
09-11-2017
WHO COLLECTS THE DATA??
Trauma Nurse
Coordinators
ED Data
In hospital course
Disposition
09-11-2017
HOW IS IT STORED??
Hard Copy
TRAUMA REGISTRY FORMS
09-11-2017
Trauma Form
09-11-2017
09-11-2017
TITCO
Towards improved trauma care outcomes in
India
Karolinska Instituet, Sweden
Tata Institute of Social Sciences
JPNATC, Delhi
LTMMC, Mumbai
Chennai
Kolkata
Srinagar
09-11-2017
Reducing the burden of injury in India and Australia through development
and piloting of improved systems of care
Benefits
More efficient data
collection
Improved data quality
Better data utility
More secure data
Registry Development
Pre-pilot: >130 variables
Post-pilot: 81variables
1 AITSC ID
2 Hospital ID
3 Data Collector
4 Observed
Dataset
PRE-HOSPITAL DATA
5 Notification-date
6 Notification-time
7 Notifier
8 Blood Pressure
9 Pulse
10 Respiratory Rate
11 AVPU
12 Estimated arrival-date
13 Estimate arrival-time
14 Communicated to
15 Date trauma callout
16 Time trauma call out
09-11-2017
Dataset
INJURY EVENT DATA
20 Injury Date
21 Injury Time
22 Injury Place
23 Injury Mechanism
24 Injury - Dominant type
25 Intent
26 Primary Vehicle
27 Patient role
28 Activity
29 Referring hospital
30 Mode of arrival
09-11-2017
Dataset
DEMOGRAPHIC DATA
31 Age
32 Gender
33 Place of residence
09-11-2017
Dataset HOSPITAL DATA
HOSPITAL DATA
34 Arrival date 48 VS1 - GCE-E
35 Arrival time 49 VS1 - GCS-V
36 Admission date 50 VS1 - GCS-M
37 Admission time 51 VS1 - GCS-Qualifier
38 Health record ID 52 ED Disposition
39 Ward(s) 53 ED Disposition-Date
40 Vital signs 1 - date
54 ED Disposition-Time
41 VS1 - time Type of Operating
42 VS1 - SBP 55 procedure
43 VS1 - HR 56 OP - Date
09-11-2017
Trauma registry form
09-11-2017
Registry software
The JPNATC/AIIMS team has developed a web-based software platform, which is in now
ready to use in ED set up for registry data collection
09-11-2017
Results
Registry has collected data from over 7000 patients at
the 4 sites
Some challenges include limitations to direct
observation data collection (especially during peak
hospital times), and low (but improving) rates of pre-
hospital and patient arrival data items.
High data completeness at 99.8 %
Intriguing data collected relating specifically to the
locale. Including prehospital care, injury mechanism,
admission demographics and hospital systems
Report of first year will be available by the end of 2017
09-11-2017
Data Completeness
0.2 % Null values
4.4 % Not Recorded or inadequately
described
09-11-2017
Registry Results
09-11-2017
Registry Results Mechanism of
Injury
09-11-2017
4.5 Admissions and deaths in Road transport accidents
73
09-11-2017
5.1 Body Regions Injured for all sites
Head n=6772 36%
Thorax n=1633 9%
Spine n= 821 4%
Abdomen n=1085 6%
Notes Body region data were derived from the first number in AIS codes
Exceptions N= 18798 74
09-11-2017
Steps in Reaching the Quality Goal
GOAL
Quality
Trauma
Care
External
Benchmarking
/Accreditation
Monitor &
Analyze
Monitor & Outcomes
Analyze
Processes
Trauma
GOAL
Registries
Existing Hosp. Data
Quality
Trauma
Care
External
Govt. Benchmarking
Process Policy makers /Accreditation
Stakeholders Monitor &
Incorporation Analyze
Structure of Protocols Monitor & Outcomes
and Processes Analyze
Manpower Monitor & Processes
Training Analyze
Specialist Trauma
Provision of Cadre Efficient
Trauma Structure
Infrastructure
Care
at all levels Optimal
Trauma
Care
Basic
Trauma
Care
Across the System (Pre-Hosp In-Hosp. Post-Acute Care)
09-11-2017
09-11-2017