global injury prevention and safety promotion catherine a. lynch, md assistant professor of em and...
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Global Injury Prevention and Safety Promotion
Catherine A. Lynch, MDAssistant Professor of EM and Global Health
Co-Director, Section EM Global Health
Eric Ossmann, MDAssociate Professor of EM
Director of Prehospital & Disaster Medicine
Overview• WHY INJURY
– Epidemiology– Why is risk increasing?
• HOW?– Surveillance/Prevention/Public Policy– Prehospital/ Hospital Trauma care quality
improvement
• PROJECTS?
Scope
Scope of Injury: US
Injury Deaths Compared to Other Leading Causes of Death for Persons Ages 1-44, United States, 2007*http://www.cdc.gov/injury/overview/leading_cod.
Types of Injuries
All Injury Deaths
Burden (GBDI, 2010)• Preliminary findings (Lancet Nov 2012)
– Injuries cause 5.1 million deaths and 12.1% DALY– All cause deaths 20% (CD 25% NCD 20%, Injuries 8%)
• Transport (28%), Falls(10%) Drowning (7%) Fires(6.6%), Self Harm (17.4%)
– RTI #8, Self Harm #13, Falls #22 cause of death– 35-45% of codes in come countries are “garbage codes”
(Argentina) so these numbers can be much higher
Injuries have a large and increasing health loss risk which is decreasing much less than other NCDs and CD
Injury Types• Intentional
– Self Directed• Suicide• Self Harm
– Interpersonal Violence• Intimate Partner• Child Abuse• Elder Abuse
– Collective Violence• War
• Non-Intentional– Transport
• Pedestrian• 4 wheel motorized (Dr/Pa)• 2 wheel motorized• 2 wheel non-motorized
– Fall– Assault
• GSW• Stabbing• Fist
– Work related Injury– Bite (Human, Animal)– Poisoning
Road Traffic Crashes• Road Traffic crashes in
low and middle income countries cost approximately $65 billion per year
• This is more than total dollar amount these countries receive in development assistance
Global Status Report on Road Safety. Geneva, World Health Organization, 2009.
Why?
• Urbanization• Motorization• Limited Care • Limited Prevention
– Road/vehicle conditions– Signage– Pedestrians/VRU– Legislation/Regulation
Violence and Homicides
SUMMARY, WHY INJURY:• >5 Million people die annually
• 16,000 people die daily from injuries
• Persons 15-44, injuries account for 6 of the 15 leading causes of death.
• For each 1 that dies, thousands have permanent sequelae Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000; 90 523-26
RF for injury
• Age• Sex• Race/ Ethnicities• Socioeconomic Groups• Alcohol/Drug• Vulnerable road users:
– Pedestrian, 2 wheel motorized and non-motorized
Development Issues• Disproportionate impact
on the poorest– More exposed to risk– Less access to prevention and care
• Disproportionate impact on young people
• High economic costs– Care– Rehabilitation– Productivity
Injury Prevention: PH Model
Study
ImplementEvaluate
Injury Prevention: Haddon Matrix
Host Equipment Physical Social
Pre-Event
Event
Post Event
Event
Injury Prevention: Haddon MatrixHost Equipment Physical Social
Pre-Event Poor VisionAlcohol UseTalking, Txting
Poor tiresFailing breaks
Narrow shoulders
Cultural norms: speeding, DUI
Event No helmets Poor helmet designs, poorly designed motorcycle
Poorly designed guardrails
Lack of vehicle design regulation/ helmet regulation
Post Event High susceptibility alcohol use
Poorly designed fuel tank
Poor EMS communication systems
Lack of Trauma system Quality
Injury Prevention: Haddon MatrixHost Equipment Physical Social
Pre-Event Poor VisionAlcohol UseTalking, Txting
Poor tiresFailing breaks
Narrow shoulders
Cultural norms: speeding, DUI
Event No helmets Poor helmet designs, poorly designed motorcycle
Poorly designed guardrails
Lack of vehicle design regulation/ helmet regulation
Post Event High susceptibility alcohol use
Poorly designed fuel tank
Poor EMS communication systems
Lack of Trauma system Quality
Injury Prevention: Haddon MatrixHost Equipment Physical Social
Pre-Event Poor VisionAlcohol UseTalking, Txting
Poor tiresFailing breaks
Narrow shoulders
Cultural norms: speeding, DUI
Event No helmets Poor helmet designs, poorly designed motorcycle
Poorly designed guardrails
Lack of vehicle design regulation/ helmet regulation
Post Event High susceptibility alcohol use
Poorly designed fuel tank
Poor EMS communication systems
Lack of Trauma system Quality
Trauma Care System
Surveillance Prevention Prehospital Care
Hospital Based Care Rehabilitation
Republic of Mozambique
“Traumas of various types, particularly those cause by road accidents, have reached epidemic proportions…”
Strategic Plan for the Health Sector 2001-2005 Ministry of Health, Republic of Mozambique
Republic of Mozambique
Maputo Central Hospital, Maputo, Mozambique
• Maputo Central Hospital– 300+ patients per day– > 30% due to Injury– Road traffic crashes are the
leading cause of death
Obstacles, Challenges and Risks
• Medical Imperialism• Financial Considerations• Political, administrative, and
regulatory• Cultural nuances and Language
Sasser SM, Varghese M, Joshipura M, Kellermann A. Preventing death and disability through the timely provision of prehospital trauma care. Bulletin of the World Health Organization, July 2006, 84 (7)
Razzak, JA and Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization, 2002, 80 (11)
Obstacle, Challenges, and Risks
• Medical Education, System, Personnel
• Capability and Capacity
• Lack of data• Human resources
Anderson P, Petrino R, Halpern P, Tintinalli J. The globalization of emergency medicine and its importance for public health. Bulletin of the World Health Organization, October 2006, 84 (10)
Razzak, JA and Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization, 2002, 80 (11)
Guiding
PrinciplesDeveloping Emergency Care Systems
SimplicityEmergency medical care systems need not be complicated and expensive. Much may be accomplished by providing simple but cost-effective treatment in a timely manner
Sustainability
Emergency medical care systems should rely on locally available supplies, equipment, training, and resources
Practicality
Implementation should not require overhaul of the country’s healthcare infrastructure
EfficiencyDesign, implementation, and operation should enable emergency medical care systems to optimally utilize the resources available to them, no matter how scarce they may be
Flexibility
Emergency medical care systems should be adaptable to suit local conditions, values, norms, and economic resources
Emergency Medical Care
Prehospital Medical Care
Estimate of world’s population covered by:
• EMS at ALS level: 5 – 15%
• EMS at BLS level: 20 – 35%
• No formal EMS: 50 – 75%
International Approaches to Trauma Care.
Trauma Quarterly, Vol. 14, No. 3, 1999.
Mock, C. Improving Prehospital Trauma Care in Rural Areas of Low-Income Countries. Journal of Trauma-Injury Infection & Critical Care. 54(6):1197-1198, June 2003.
Improving prehospital care
• Strengthen existing prehospital care systems– Organization/administration/quality
– Logistics and operations
– Deployment• Target high risk areas
–Training and Education
Page 1
Maputo Prehospital Assessment and Initial Planning
Maputo City Prehospital Assessment
Report Complete
Identify Key Stakeholders
· Agency (Individual) in Charge
· Medical Direction· Multi-Disciplinary
Emergency Care Committee
Institute First-Responder Training
· Community Associations
· Volunteers· Community Activists· Police Officers· Commercial Drivers· Private Drivers
Strengthen Emergency Care at
Fixed Facilities
Improve Access to the Emergency Care System
· Universal Number· Public
Information Campaign
Institute Basic Prehospital Care
Program
Institute System of Ambulance Transportation
· Train Professional Responders
· Strengthen Existing Infrastructure
Sasser, et al. Assessment of Emergency Medical Services in Maputo, Mozambique. Prepared for the World Health Organization, 2005
Making it Successful• Government support• Academic support• Provider support• Institutional support• Community support• Long-term
commitment
Current EM GH Projects
How to get involved?
Tucumán, Argentina
Surveillance
Qual
Quant
Prevention
Address RF
Community Initiatives
Public Policy
Prehospital Care
QI
Protocols
Training
Hospital Based Care
QI
Protocols
Training
Rehabilitation
Needs Assessment
Occupational Tx
Tucumán, Argentina
• Aim: Develop a evidence based provincial injury prevention initiative
• Location: Tucumán, Argentina
• Methods:– Community Based Qualitative**– Hospital Based Quantitative**
Moshi, Tanzania
Surveillance
Qual
Quant
Prevention
Address RF
Community Initiatives
Public Posicy
Prehospital Care
Time Studies
QI
Education
Hospital Based Care
QI
Protocols
Training
Rehabilitation
Needs Assessment
Occupational Tx
Moshi, Tanzania
Surveillance
Qual
Quant
Prevention
Address RF
Community Initiatives
Public Policy
Hospital Based Care
QI
Protocols
Training
Moshi, Tanzania
Aim: To determine the burden of injury at KCMC and the increased risk of injury due to alcohol
Location: KCMC, Moshi Tz
Methods: Hospital Based Epidemiology• Healthcare worker KAP study • Self-survey• Nested case crossover
Moshi, Tanzania
Aim: To improve TBI acute care management
Locations: KCMC, Moshi Tz
Methods: • Systematic Review• Mediated Modeling*• TBI Protocol Evaluation*
QUESTIONS?