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?