OVERVIEW Emergency and Trauma Care Systems The DCP emergency components of essential packages WHO Emergency Care System Framework Emergency Care System Assessment Tool
PREVENTION PREHOSPITAL & TRANSPORT TRAUMA FACILITY-BASED CRITICAL CARE EMERGENCY CARE SYSTEMS SYSTEMS REHABILITATION
Of 45 million annual deaths in LMICs, 54% are due to conditions addressable by prehospital and emergency care. 1,023 million DALYs, 932 million years of life lost to premature mortality.
Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. Kobusingye, Bulletin of WHO
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Essential packages at each level of the health system include emergency components.
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Post-GBV care (prevention of STI/HIV, emergency contraception, support/counseling) Management of unintended pregnancy Management of miscarriage/incomplete abortion and post abortion care* Antibiotics for pprom Tetanus toxoid* Screening for complications of pregnancy Initiate antenatal steroids (as long as clinical criteria and standards are met)* Initiate magnesium sulphate Detection of sepsis First Level Hospital Management of labour and delivery in high risk women Caesarean Vacuum extraction/forceps delivery Ectopic pregnancy Vacuum aspiration and dilatation and curette Hysterectomy for uterine rupture or intractable post-partum haemorrhage Antenatal steroids* Magnesium sulphate Treatment of sepsis Induction of labour post-term Ectopic pregnancy case management* Detection and management of fetal growth restriction* * Denotes that the intervention effect was included in the Lives Saved Tool (LiST).
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Child and Newborn Health Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Post-GBV Community care Facility (prevention of STI/HIV, emergency contraception, support/counseling) Management Detect and refer of unintended severe acute pregnancy malnutrition Management Detect and treat of miscarriage/incomplete serious infections without abortion danger and signs post abortion care* Antibiotics Thermal care for for pprom preterm newborn Tetanus Neonatal toxoid* resuscitation Screening Oral antibiotics for complications for pneumonia of pregnancy Initiate antenatal steroids (as long as clinical criteria and standards are met)* Initiate Primary magnesium Health Centre sulphate Detection Treat severe of acute sepsismalnutrition Detect and treat serious infections with danger signs* First Kangaroo Level mother Hospital care Management Injectable and of oral labour antibiotics and delivery for sepsis, in high pneumonia risk women and meningitis Caesarean Jaundice management Vacuum extraction/forceps delivery Ectopic First Level pregnancy Hospital Vacuum Treat severe aspiration acute malnutrition and dilatation associated and curette with serious infection* Hysterectomy Detect and treat for serious uterine infections rupture or with intractable danger post-partum signs with full haemorrhage supportive care* Full supportive care for preterm newborn* Treatment of newborn complications, meningitis and other very serious infections* * Denotes that the intervention effect was included in the Lives Saved Tool (LiST).
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Child and Newborn Health Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Injury Post-GBV Community care Facility (prevention of STI/HIV, emergency contraception, support/counseling) Management Detect and refer of unintended severe acute pregnancy malnutrition Community Facility and Primary Health Centre Management Detect and treat of miscarriage/incomplete serious infections without abortion danger and signs post abortion care* Resuscitation with BLS measures Antibiotics Thermal care for for pprom preterm newborn Suturing laceration Tetanus Neonatal toxoid* Management resuscitation of non- displaced fractures Screening Oral antibiotics for complications for pneumonia of pregnancy Initiate antenatal steroids (as long as clinical criteria and standards are met)* First Level Hospital Initiate Primary magnesium Health Centre sulphate Resuscitation with advanced life support measures, including surgical airway Detection Treat severe of acute sepsismalnutrition Tube thoracostomy (chest drain) Detect and treat serious infections with danger signs* Trauma laparotomy First Kangaroo Level mother Hospital Fracture reduction care Management Injectable and of oral labour antibiotics and delivery for sepsis, in high pneumonia risk women Irrigation and debridement of open fractures and meningitis Caesarean Jaundice Placement management of external fixator; use of traction Vacuum extraction/forceps delivery Escharotomy/fasciotomy (cutting of constricting tissue to relieve pressure from swelling) Ectopic First pregnancy Trauma-related amputations Burr hole
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Child and Newborn Health Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Injury Post-GBV Community care Facility (prevention of STI/HIV, emergency contraception, support/counseling) Management Detect and refer of unintended severe acute pregnancy malnutrition Community General Surgical Facility and Primary Health Centre Management Detect and treat of miscarriage/incomplete serious infections without abortion danger and signs post abortion care* Resuscitation with BLS measures Antibiotics Thermal care for for pprom preterm newborn Suturing Community laceration Facility and Primary Health Centre Tetanus Neonatal toxoid* Management Drainage of resuscitation superficial of non- displaced abscessfractures Screening Oral Drainage antibiotics of for septic complications for arthritis pneumonia of pregnancy Initiate antenatal steroids (as long as clinical criteria and standards are met)* First Debridement Level Hospital of osteomyelitis Initiate Primary magnesium Health Centre sulphate Resuscitation with advanced life support measures, including surgical airway Detection Treat severe of acute sepsismalnutrition Tube First Level thoracostomy Hospital (chest drain) Detect and treat serious infections with danger signs* Trauma Repair of laparotomy perforations: for example, perforated peptic ulcer, typhoid ileal perforation First Kangaroo Level mother Hospital Fracture Appendectomy reduction care Management Injectable and of oral labour antibiotics and delivery for sepsis, in high pneumonia risk women Irrigation Bowel obstruction and debridement of open fractures and meningitis Caesarean Jaundice Placement Colostomymanagement of external fixator; use of traction Escharotomy/fasciotomy Gallbladder disease, including (cutting emergency of constricting surgery tissue to relieve pressure from swelling) First Level Hospital Trauma-related Hernia, including amputations incarceration Treat Relief severe of urinary acute obstruction: malnutrition catheterization associated with or suprapubic serious infection* cystostomy
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Child and Newborn Health Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Injury Post-GBV Community care Facility (prevention of STI/HIV, emergency contraception, support/counseling) Management Detect and refer of unintended severe acute pregnancy malnutrition Community General Surgical Facility and Primary Health Centre Management Detect and treat of miscarriage/incomplete serious infections without abortion danger and signs post abortion care* Resuscitation with BLS measures Antibiotics Thermal care for for pprom preterm newborn Suturing Community Mental, laceration Neurological, Facility and Primary and Health Substance Centre Abuse Disorders Tetanus Neonatal toxoid* Management Drainage of resuscitation superficial of non- displaced abscessfractures Screening Oral Drainage Community antibiotics of for Facility septic complications for arthritis pneumonia and Primary of pregnancy Health Centre Initiate antenatal steroids (as long as clinical criteria and standards are met)* First Debridement Management Level Hospital of osteomyelitis prolonged seizures or status epilepticus (neurological disorders) Initiate Primary magnesium Health Centre sulphate Resuscitation Emergency management with advanced of poisoning life support (suicide measures, and self-harm) including surgical airway Detection Treat severe of acute sepsismalnutrition Tube First Level thoracostomy Hospital (chest drain) Detect and treat serious infections with danger signs* Trauma Repair First Level of laparotomy perforations: Hospital for example, perforated peptic ulcer, typhoid ileal perforation First Kangaroo Appendectomy Diagnosis Level mother and Hospital management care of acute psychoses (mental health disorders) Management of severe dependence and withdrawal (alcohol and illicit drug use) Specialised Care Electroconvulsive therapy for severe or refractory depression (mental health disorders)
EMERGENCY COMPONENTS OF ESSENTIAL PACKAGES Obstetric, Gynecologic, Reproductive Health and Family Planning Child and Newborn Health Community Facility and Primary Health Centre Management of labour and delivery including initial treatment of complications Injury Post-GBV Community care Facility (prevention of STI/HIV, emergency contraception, support/counseling) Management Detect and refer of unintended severe acute pregnancy malnutrition Community General Surgical Facility and Primary Health Centre Management Detect and treat of miscarriage/incomplete serious infections without abortion danger and signs post abortion care* Resuscitation with BLS measures Antibiotics Thermal care for for pprom preterm newborn Suturing Mental, laceration Neurological, and Substance Abuse Disorders Tetanus Neonatal toxoid* resuscitation Screening Oral Cancer antibiotics Care Community for Facility complications for pneumonia and Primary of pregnancy Health Centre Initiate antenatal steroids (as long as clinical criteria and standards are met)* Primary Community Health Facility Centre and Primary Health Centre Treat Hep B severe vaccination acute (including malnutrition birth dose) First Level Hospital Emergency surgery for obstruction
WHO EMERGENCY CARE SYSTEM FRAMEWORK
EMERGENCY CARE SYSTEM FRAMEWORK Document of consensus-based essential components of emergency care systems. Designed for ministries, policy makers, health system administrators, and general advocacy Facilitates the identification of system gaps to aid in priority setting.
WHO EMERGENCY CARE SYSTEM FRAMEWORK
WHO EMERGENCY CARE SYSTEM FRAMEWORK Scene Transfer Facility Bystander Response Dispatch Provider Response Patient Transport Transport Care Reception Emergency Unit Care Disposition Inpatient Care
SCENE WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Bystander Response Components System Activation Bystander Care
SCENE WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Bystander Response Dispatch Components System Activation Bystander Care Instructions to Bystanders Dispatch of Personnel
SCENE WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Bystander Response Dispatch Provider Response Components System Activation Bystander Care Instructions to Bystanders Dispatch of Personnel Scene Control Scene Care Field to Facility Communication Destination Triage
TRANSFER WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions
TRANSFER WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Patient Transport
TRANSFER WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Patient Transport Transport Care
FACILITY WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Components
FACILITY WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Reception Components Registration Screening Triage Handover
FACILITY WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Reception Components Registration Screening Triage Handover Emergency Unit Care Initial Assessment & Resuscitation Monitoring and Revaluation Detailed Assessment Diagnostic Studies Additional Therapeutics Establishing Diagnoses
FACILITY WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Reception Components Registration Screening Triage Handover Emergency Unit Care Disposition Initial Assessment & Resuscitation Monitoring and Revaluation Detailed Assessment Diagnostic Studies Additional Therapeutics Establishing Diagnoses Communication System with Protocols
FACILITY WHO EMERGENCY CARE SYSTEM FRAMEWORK Site Primary Functions Reception Components Registration Screening Triage Handover Emergency Unit Care Disposition Inpatient Care Initial Assessment & Resuscitation Monitoring and Revaluation Detailed Assessment Diagnostic Studies Additional Therapeutics Establishing Diagnoses Communication System with Protocols Early Operative Care Early Critical Care
WHO EMERGENCY CARE SYSTEM FRAMEWORK Scene Transfer Facility Bystander Response Dispatch Provider Response Patient Transport Transport Care Reception Emergency Unit Care Disposition Inpatient Care
WHO EMERGENCY CARE SYSTEM FRAMEWORK
EMERGENCY CARE SYSTEM ASSESSMENT TOOL
EMERGENCY CARE SYSTEM ASSESSMENT TOOL An instrument for internal or external assessment of national or sub-national emergency care systems. Survey structure in which answers represent progressive stages of system development Creates roadmap functionality to guide priority setting. Goal is to generate priority action plans
ECS ASSESSMENT TOOL
Emergency unit staffing in first-level referral facilities: First-level referral facilities are the lowest level of facility that receives referrals. In many countries, these are district hospitals. An emergency unit is any dedicated intake area for acutely ill and injured patients. This may be referred to as the Emergency Department/Room/Ward, Accident and Emergency, Casualty, etc. There are no dedicated emergency units or no providers with specific responsibility for emergency unit patients until they are admitted. There are non-doctor staff that register and direct patients from the emergency unit to inpatient areas (the unit has a sorting function, but minimal care is provided). 1 2 Doctors from inpatient services have on-call responsibility to cover emergency unit patients, but are not assigned to be in the emergency unit. Doctors from inpatient services are assigned to be in the emergency unit, rotating through for limited intervals (e.g. 1 month blocks). There are non-rotating providers that permanently staff the emergency unit. 5 I don t know. Cannot answer for another reason (explain): 3 4
WHO EMERGENCY CARE SYSTEM FRAMEWORK
PREVENTION PREHOSPITAL & TRANSPORT TRAUMA FACILITY-BASED CRITICAL CARE EMERGENCY CARE SYSTEMS SYSTEMS REHABILITATION
625,000 RTI deaths SDG 3.6 RTI fatality reduction target Mock et al. (2012) An Estimate of the Number of Lives that Could be Saved through Improvements in Trauma Care Globally. WJS
Lives potentially saved every year in LMIC by improvements in trauma care 625K 562,000 RTI deaths SDG 3.6 RTI fatality reduction target Mock et al. (2012) An Estimate of the Number of Lives that Could be Saved through Improvements in Trauma Care Globally. WJS
Emergency Care and SDG Targets 3.1: Reduce by three quarters, between 2015 and 2030, the maternal mortality ratio Treatment for obstetric emergencies 3.2: Reduce by three quarters, between 2015 and 2030, the under-five mortality rate Treatment for diarrhea and pneumonia 3.3: Reverse the incidence of malaria and other major diseases and ensure that deaths caused by these diseases are reduced by a half in 2030 Treatment of acute infections and sepsis 3.4: By 2030, reduce by one-third premature mortality from NCDs Treatment of exacerbations of NCDs 3.5: Strengthen the treatment of substance abuse Emergency unit care and harm reduction interventions 3.6: Halve the burden due to global road traffic crashes by halving the number of fatalities and serious injuries by 2030 compared to 2010. Post-crash emergency care 3.8: Achieve universal health coverage including financial risk protection and access to quality essential healthcare services Emergency care is an essential component of health care 11.5: By 2030, significant reduce the number of deaths and people affected caused by disasters Disaster preparedness and response for resilient health systems
EMERGENCY CARE: DISEASE CONTROL PRIORITIES
The WHO Emergency Care System Framework and associated assessment tool are designed to characterize system gaps, set planning and funding priorities, and establish monitoring and evaluation strategies for system strengthening and development. Emergency care system strengthening will be essential for increasing global capacity for the emergency procedures DCP essential packages at each level of the health system include. Need to summarize and synthesize evidence of the effectiveness of emergency care interventions and provide comparative economic evaluation of policies to implement those interventions.
PRE-HOSPITAL CARE