Hospital Care and Trauma Management Nakhon Tipsunthonsak Witaya Chadbunchachai Trauma Center Khonkaen, Thailand Health protection and disease prevention Needs Assessment Disasters usually have an unforeseen, serious, and immediate affect on health. They do not only cause victims but also attracts considerable attention. Either family member, friends of the victims, people who voluntary assist, health organization and also the media, are instead of providing help, interfere with the work of the medical and paramedical personnel. This disorder happened in every sites of the disaster. Health protection and disease prevention during the disaster within hospital is fully integrated into the emergency medical service (EMS) system and strives to meet the needs of all injured patients requiring an acute care facility, regardless of severity of injury. The system recognizes the necessity of other health care facilities. The goal is to match a facility s resources with a patient s needs so that optimal and cost-effective care is achieved. The appropriateness of the infectious control during the disaster in Khonkaen Trauma Center was being done parallel with the medical resuscitation life-support and rehabilitation. A definitive specialized care facility is a key component of the system. The adequacy of health protection and disease prevention coordinates care among all levels of injuries. One of the most common failures in system development is to designate too many trauma centers. It means the dilution of the experience necessary to maintain trauma expertise and adequate levels of training and for educational opportunity and research. The public support begun by establishing the need for trauma care improvement, injured patient database, resources assessment and management should have been reconsidered for the future planning, including the hospital providers and facilities for acute care, specialty and rehabilitative. The effectiveness of health protection was involved at the beginning in trauma care system. The indicator for essential service was prepared to carry out the receiving casualties, either direct or from first aid posts, providing initial, casualty care, and marking non-critical cases to be transferred to their home or base hospital. The efficiency for disease prevention in hospital was controlled by the triage system on arrival at the emergency department. Triage is often based on incomplete information because the detailed information and status of patient may not be immediately obtainable. However, decisions have to be made on the best information available. Frequently, it is not possible to obtain such parameters as vital signs on the victims in multiple casualties. In deed, it is necessary in many instances to make decision by surveying an entire situation at a distance and determining on that basis which of the patients are most severely injured. Part of the triage process also involves a determination of the most appropriate mode of transfer to definitive care including the efficiency tetanus prophylaxis and adequate preparation for contingencies during the transfer process. The connectedness of the aspects both national and international intervention in technical and organizational is the needs of initial assessment in order of prioritized in multiple victims. In some instances it may be necessary to prioritize patients based on salvage ability. The guideline 1 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc
should be done standardized nation wide in providing resources for optimal care of the injured patient, consultation for trauma system, and guideline for trauma care system. It is fundamental to the development of a system that the number of designated trauma centers be limited to those necessary for the patient population at risk for major injury. A complete dataset, including data from acute care facilities, will allow accurate determination of where injured patients received their care and therefore can establish the true rate of over- and under-triage. Coordination The Khonkaen Trauma Center coordinates with Khonkaen University hospital, Srinagarind. The resources management for mass casualty is integrated for optimal care in both institutions. It is appropriate for considering the correlation with constant liaison to the police and local administration to be maintained so that early information about the expected number and nature of casualties being sent to the hospital is readily available. The past disaster in the South of Thailand indicated that we still need an adequacy of proper equipment and effective personnel in communication in aspect of the medical report. The continuing of casualty care as needed in hospital required an effectiveness coordination from the site of incident. The health protection for injured patients needed as important as disease control and prevention due to the referral system with the core efficiency personnel. The intervention for coordinating in health protection should need support from United Nations both the technical and organizational to maintain the standard of expectation in caring the mass casualty. Gap filling During the situation in December, 2004, survivals and other outcomes measured after the complex surgical procedures correlate directly with the volume of experience for both institution and the surgeons, supporting concentrating and limiting resources to care for injured patients with a defined geographic area. Qualified general surgeons were expected to participate in major therapeutic decisions and were presented in the emergency department for major resuscitations and at operative procedures in all seriously injured patients. 24-hour-in-house availability of the attending surgeons was the most direct method for providing this involvement. A postgraduate year 4 or 5 resident was approved to begin resuscitation while awaiting the arrival of the attending surgeons. Additionally, the attending general surgeon would be responsible for the timely evaluation every trauma admission. It could say that there were never enough surgeons who can perform correctly advanced trauma life support. But what did happen show that we have done the best for the arrival of the casualties. This institution is expected to manage large numbers of injured patients with a certain severity of injury. This trauma hospital is not only serves as the lead trauma facility but also expected to have an outreach program which incorporates smaller institutions in their service area. This should accomplish all the effectiveness in the population-dense area of Khonkaen and as well supplements the clinical activity and expertise of a level 1 institution. It is more efficiency working together to optimize resources, cooperative environment. Capacity Building The country capacities being strengthened so as to be better prepared for the future disasters by having a standardized national planning. All principles player must be involved at the beginning. In the inclusive system, consideration must be given to the role of all the acute care 2 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc
facilities in the area which care for injured patients. Representatives from these non-trauma center facilities must be included in the planning process appropriately. The financial consideration is the most important key for adequate in classification system and the assessment true needs for trauma care. Especially the effectiveness of trauma center is up to the limitations on the number of verified trauma centers within the given area. The efficiency of a good trauma system is the availability of dedicated, efficient health care professionals. The aspects of national and international intervention for better preparation in future disasters in both technical and organizational is to improve and integrate the number of knowledgeable facility and health care personnel in trauma care, especially in mass casualty. Health Services delivery Needs Assessment On arrival, principal management is to derive from concept developed to detect specific injuries defined prospectively by protocol triage. The appropriateness is to know the mechanism of forces which could lead to severe injury and to provide on-scene initial assessment and management due to the advanced trauma life support guidelines. For medical direction on arrival the hospital is by preexisting protocol/indirect medical direction. Protocols which guide patient care is established by trauma health care providers such as surgeons, emergency physician, medical director for ambulance service, and trained basic and advanced emergency medical personnel. For the effectiveness in assessing the needs is to initiate of resuscitation by establishing survey from ABCs. The disaster plan should establish in advance of the mechanisms necessary for identification and registration of the patients who are admitted. The forms for recording data, identification cards, and card for triage should be available and accessible efficiency. Registration forms, which subsequently will serve to document the clinical history, should be designed to collect the most essential information. The use of triage cards, whatever the model, should be standardized whenever possible and accepted by the community in such a way that the emergency medical services and the hospital are familiar with their use. Technically when there happened to be a mass casualty, the hospital takes measures to expand its care capacity, many cases may require specialized care for which the Khonkaen Trauma Center is not equipped such as the cardio vascular surgery, or simply the demand exceeds the hospital s capacity, for these cases, the plan should envision the alternative of referring patients to other hospital of which allied and coordinates. This highlights the need for an organized network within the community for example, the referral system from Khonkaen Trauma Center to University Hospital nearby or to private hospitals surrounding in sub-rural area. Coordination Khonkaen Trauma Center can be notified of a disaster from various sources, the police, the fire department, the emergency ward, or individuals. The operator on duty or the person notified should identify the person sequentially starting from staff at the ER then to the call center (1669- Nation Wide) and spread throughout the personnel involved named in disaster written plan appropriately. 3 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc
The communication inadequacy is always number one of the main problem in every mass casualty occurrences. The lack and shortness of medical chief commander both in ER and at the disaster sites, made the loss of golden period for life-saving in many cases. The problem was that we have too many commanders. The confusion occurred during the initiate working zones. Finally every volunteer and medical personnel all work individually without correlation or cooperation due to the conflict between the commanders themselves. The effectiveness communication should be established in the same standard and be announced to be used throughout the country. Job description for the commander in each field should be made as a protocol which guide to rapid transportation to the appropriate facility. The indicator to maintain the efficiency of the coordination is including of the resources management and sharing within the allied health care institutional and provider. An internal system of communication between the hospital various wards and, departments must be improved such as the portable loud speakers, internal telephone lines, and two-way radios are a few possible alternatives. The planning for improvement should include arrangements for communicating with off-duty hospital staff. Usually, each hospital employee contacts two or three previous designated colleagues. The sophisticated communication system in hospital should be standardized as in the worldwide. Gap filling The needs of the patient in mass casualty are the timely and efficient emergency medical care, as well as ensure the rational use of ground and air transport, communication coordination between the hospital and the various agencies involved of vitalities. Each activity of hospital care requires a response time and the likelihood of the victims survival is reduced if the total response time, between notification of the disaster and care at a hospital, is prolonged. The inadequacy in coordination between the hospital staffs and each other rescuer members is quite a main problem in the transferals system. A periodic inventory of ambulances, mobile unit, and other in-service vehicles contributes ineffectively to the operating capacity of a hospital. The plan should be improved in clearly indicate priorities regarding the use of hospital vehicles. The problem occurred while there was no provision for fuel and designates staff to be in charge. The efficiency for equipment used to move patients, such as stretchers and wheelchairs, should be inventoried and areas designate for storage and circulation inside the hospital. The staff assigned to the incoming patient and the staff on duty at key services, should use some form of visible identification for organization as services as well as security reasons. Key personnel should identify themselves with a colored armlet or badge. Capacity Building Thailand are being strengthened for better prepared for future disasters by establishing the specific manual for each department or ward, as well as instructions how to establish personnel working, groups, lines of command, alternate leadership, and relationships with other institutions. The major cause of inadequacy documents is the various practice guidelines of which being used in vary trauma center. The clearly set of documents should be identified and easy to get to. Furthermore, instruction cards should be conspicuously placed in each hospital room indicating actions to be taken incase of emergency. The effectiveness for successful disaster preparation is the up to date staff training. Ongoing training must be provided covering all aspects of the plan. Drills should be carried out once a year to test and improved the efficiency of the plan. Khonkaen Trauma Center carry out the rehearsal for 4 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc
disaster simulation once a year, using the difference scenarios in varies situations involvement with the mass casualties. Health policy and coordination Needs Assessment The appropriateness of health policy of Khonkaen Trauma Center is to provide comprehensive trauma care in two distinct environments. The first is in the population-dense area where level II supplements the clinical activity and expertise of a level I institution. The second for the level II serve in less population-dense areas as the lead trauma facility. Khonkaen Trauma Center has beds available at 800 and can be admitted up to 120%. Furthermore, from the correlation between the university hospital and the privates, the mass casualties can be transferred up to approximately at 1,200. The administrative support is adequacy in providing the human resource management, educational activities, community outreach activities, and community cooperation. The medical staffs at Khonkaen Trauma Center have a commitment to support the trauma program by their professional activities to provide enough specialty care to support the optimal care of the injured patient. Each discipline provides the appropriate skills as team members working in correct implement treatment based upon a prioritized plan of care. The effectiveness performance improvement evaluation of this care must extend to all over the involved departments. A board certified surgeon (usually general surgeon) with special interest in trauma care acts as a trauma director at Khonkaen Trauma Center. The director leads the multidisciplinary activities efficiency of the trauma program such as developing trauma protocol, cooperating with the nursing administration to support the nursing needs of the trauma patients. Khonkaen Trauma Center has a trauma team with a high level response to a severely injured patient. The services include adequate personnel and other resources necessary to ensure appropriate and efficient care delivery. Coordination Khonkaen Trauma Center guarantees immediate availability of specialized surgeons, anesthesiologist, other physician specialists, nurses and resuscitation life-support equipments 24 hours a day. The system coordinates care among all levels of trauma centers and facilities so that efficient and prompt interfacility communication and transfer can take place according to patient need. Access to rehabilitation service, initially in the acute care hospital and subsequently in more specialized facilities is one of the coordination policies. Gap filling The need for resources is primarily based on the concept of being able to provide immediate medical care for unlimited numbers of injured patient at any time. Optimal resources at such a trauma center would include in-house board-certified emergency medicine physicians, general surgeons, anesthesiologist, and specialty board surgeons. This center would require a certain volume of injured patient to be admitted each year, and these patients would include the most severely injured patient within the system. Quality and cost effectiveness will improve with experience and patient volume. Certain injuries that are infrequently seen would be concentrates in this special center to ensure that these patients could be properly treated and studied, providing the opportunity to improve the care of these patients. 5 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc
Capacity Building The Khonkaen Trauma Center would have an integrated concurrent performance improvement (PI) program to ensure optimal care and continuous improvement in care. This center would also be responsible for assessing care delivered not only within its trauma program, but also within the entire trauma system. One resource of a trauma center that can not be limited is the surgical commitment and surgical leadership. This commitment is a valuable resource which is integral to a successful trauma program. REFERENCES Health Sector Contingency Plan for Management of Crisis Situation in India. Part III Guidelines for Mass Casualty Management Hospital Contingency Plan. Citation on Web Searched. April 2005 Schwartz, Richard B. Hospital Preparedness for Mass Casualty Disasters. Paper Presented at the Annals of Emergency Medicine Conference. 2004 American College of Surgeons Ad Hoc Committee on Disaster and Mass Casualty Management of the Committee on Trauma. Statement on disaster and mass casualty management. 2003 Chadbunchachai, Witaya. Field Commander. Paper Presented at the Commander in Mass Casualty Situation Conference. Khonkaen, Thailand. 2003 Chadbunchachai, Witaya. Disaster Plan for Trauma and Critical Care Center Khonkaen Regional Hospital.. January 2002 Green, Walter G. Integrated Medical Disaster Response: A Case Study of the Virginia Emergency Medical Services System. Paper presented at the American Academy of Medical Administrators Conference. 2001 Committee on Trauma. American College of Surgeons. 1999 Mass Casualties. Resources for Optimal Care of the Injured Patients: 1998 6 2_5_mass_casualty_hospital_care_tipsunthonsak_doc.doc