The 2014 Academic College of Emergency Experts in India's INDO-US Joint Working Group (JWG) White Paper on "Developing Trauma Sciences and Injury Care in India"

Epidemiology of Pediatric Musculoskeletal Trauma Patients Admitted to a Trauma Center in Northern India: A Prospective Cohort Study

Background Pediatric injuries are the leading cause of death and disability worldwide and place a considerable burden on nations with limited resources. A careful investigation of the epidemiology of pediatric musculoskeletal trauma can provide insight into its causation and the demography of the affected children and help us devise preventive strategies to reduce the burden of pediatric musculoskeletal trauma. Methodology Musculoskeletal trauma patients up to the age of 18 years were included in this prospective cohort study. Information about age, sex, time since the injury to presentation to a trauma center, mode of injury, the site where the injury was suffered, and the exact injury were recorded. Age was further recorded as 0 to 3 years, >3 to 6 years, >6 to 12 years, and >12 to 18 years. A subgroup analysis of the mode of injury was done using age group and sex.  Results A total of 201 patients were enrolled in the study. The age (mean ± standard deviation [SD]) of the enrolled patients was 12.48 ± 4.71 years. Of the 201 patients enrolled, 146 (72.63%) were males. The mean time since the injury to the reception in the emergency department of the King George's Medical University trauma center (a tertiary care center) was 19.13 ± 33.86 hours. The common mechanisms of injury observed were road traffic accidents (RTAs, 55.22%), falls from height (29.35%), and falls at ground level. There was a significant difference in the mode of injury in the age groups (P = 0.0297) and among males and females (P = 0.0034). Injuries to the lower limbs were most common in all age groups. Conclusions Our study presents the baseline epidemiological data on pediatric musculoskeletal injuries distributed by age groups, gender, mode of injury, site of injury, and region-wise distribution of injuries. The data may be used by policymakers in planning a pediatric trauma care system in India.

Critical Appraisal of Traumatic Brain Injury and Its Management

Critical appraisal of traumatic brain injury (TBI) management has always been marred with a conflict of differential approaches, with claims and counterclaims of outcomes among the research groups. We performed this study to review the management of TBI from risk factors to outcomes including the comorbidities and final clinical status. In conjunction with the aforesaid stabilization of TBI cases, prophylactic and definitive surgical approaches and other supporting interventions will ultimately decide the final outcomes in the long run. Improvements in the quality of care for patients with severe TBI, with the reduction in mortality, have been demonstrated in high-income areas due to improvements in the health care system and not just in one isolated intervention. In the management of TBI, a fast and high index of suspicion is the key to success, from the initial assessment to the final rehabilitation of the cases, from the victim of risk factors to the victims of situation. The research groups feel that TBI prophylactic measures and primary care mitigation models are as important as definitive care, starting from prehospital care to dedicated care.

Pediatric Trauma: Management and Lessons Learned

Aim:

The aim is to prospectively study 125 trauma patients admitted in the pediatric surgery ward in our institute.

Materials and Methods:

Pediatric patients admitted in the ward after initial resuscitation in the triage room were included. Isolated neurosurgical and orthopedic injuries were excluded. X-ray cervical spine, hip, and chest and a focused assessment with sonography in trauma ultrasound were done for all patients. Computed tomography of the abdomen or chest was done where relevant. Injury profile and surgical intervention when needed were analyzed.

Results:

Road traffic accidents and fall from height caused 73.6% of the injuries. School-going children were most commonly affected (60.8%). Distinctive injuries were noted such as abdominal wall hernias and delayed bladder perforation. All solid organ injury irrespective of grade treated conservatively. Forty percent of the children required surgical intervention. Five patients after laparotomy were found to have surgical conditions unrelated to trauma, whereas another 14 required delayed surgery. Five patients had injuries secondary to sexual abuse. All except two patients were discharged in a satisfactory condition and are doing well in the follow-up.

Conclusion:

In spite of extensive injuries and the need for multiple surgeries, children with trauma have a good prognosis. Close observation during admission and also in follow-up are essential, as many patients may require delayed surgery ≥1 week from injury.

A multicenter observational cohort study of 24 h and 30 day in-hospital mortality of pediatric and adult trauma patients - An Indian urban tertiary care perspective

BACKGROUND/PURPOSE

India with its evolving trauma system needs multicenter studies on trauma outcomes to help determine the need for planning and structuring care better and to bridge the gap between the burden of disease and research. Therefore here we studied 24 h and 30 day mortality in adult and pediatric trauma population presenting to urban tertiary care hospitals.

METHODOLOGY

Data from multicenter observational cohort study conducted from July 2013 to December 2015, Towards improved trauma care outcomes in India (TITCO) were used.

MAIN FINDINGS

3381 pediatric and 12,666 adult trauma patients. Unadjusted analyses of mortality were significantly less in pediatric compared to adult group within 24 h (OR 0.513, 99% CI 0.4-0.658, p < 0.001) and 30 days (OR 0.442, 99% CI 0.383-0.511, p < 0.001). In adjusted analyses pediatric group did not have significantly lower odds of 24-h mortality (OR 0.778, 99% CI 0.106-5.717, P = 0.746). At 30 days, pediatric group had 89% lower odds of death compared to adults (OR 0.11, 99% CI 0.017-0.0714, p = 0.002).

CONCLUSION

Children had mechanisms of injury different from adults leading to less severe injuries than adults. Children are more likely than adults to survive until 30 days after admission for trauma in urban India.

LEVEL OF EVIDENCE

Level II.

Going to the nearest hospital vs. designated trauma centre for road traffic crashes: estimating the time difference in Delhi, India

Background: Time to hospital after a road traffic crash (RTC) plays a vital role in determining the outcome for crash victims. In Delhi, there are seven designated trauma centres where crash victims are typically taken, which may not be nearest hospital. We compare the transport time access (crash to hospital) depending on whether the victim is transported to a designated trauma centre or the nearest hospital. Data and methods: For each RTC geocoded manually from police records, the nearest hospital and the designated trauma centre is identified using Google Maps places nearby Search API and guidelines. Travel time matrix is generated between RTC's and identified hospitals using Google maps distance matrix API. Index accounting inter-district differences is developed. Results and conclusions: The network of designated trauma centres in New Delhi is located such that they can be accessed within 45 min of most crashes while nearest hospital within 30 min. As a result, the vast majority of crash victims are likely to receive timely care if they are rapidly transferred to either of these caregivers. However, for the most severely injured and time-sensitive cases, bypassing nearest hospital for trauma care, could substantially improve survival outcomes.

Public health crisis of road traffic accidents in India: Risk factor assessment and recommendations on prevention on the behalf of the Academy of Family Physicians of India

Roads are considered a sign of development bringing colossal benefits to community as socioeconomic and logistic facilitator. Yet, growth of road network has brought road crashes leading to civic pain from premature deaths of productive age group. In 2017, 16 citizens were killed and 53 injured every hour on Indian roads as per officially reported data, while a fair number go unreported. This is unacceptably high when compared with international standards. Risk correlates of road traffic injuries (RTIs) need to be redefined so as to form a continuum with other confounding factors that impact to take lives on road. Risk factors impacting RTIs vary from human components to the roles and responsibilities of healthcare stakeholders. We should have made roads safer for all citizens because a large percentage of population – children, pedestrians, cyclists, motorcyclists, and the elderly – are most vulnerable. A taskforce was set up by the Academy of Family Physicians of India to scientifically analyze the literature available to assess risks and put forward appropriate recommendations.

The "Case-Based Learning Conference" Model at EMINDIA2017: A Novel Implementation of Problem-Based Educational Paradigm

INDUSEM was established as an INDO-US Satellite Knowledge Network in 2005. It brought together the academic leaders and innovators from India and the US with the goal of creating collaborative synergies and creative solutions to advance the knowledge and science of emergency medicine (EM) in India. Since 2005, the leadership of INDUSEM devoted substantial resources, effort, and expertise to ensure that newly implemented clinical institutes and training programs have the necessary resources and logistical support to effectively advance EM and Traumatology Sciences in India. As a result, significant synergies and progress were achieved toward establishing EM training programs and building clinical infrastructure through education, grant funding, research, skills development, bidirectional collaborations, and sustained influence on public health policy development. As INDUSEM's mission matures, its efforts will increasingly focus on creating long-term sustainability across clinical, didactic, educational, outreach, health policy, and research domains. In this joint statement, the authors describe the evolution of INDUSEM's institution of INDO-US Summit into the World Academic Congress of EM , with the parallel inception of an India-centric academic enterprise, EMINDIA.

A bibliometric analysis of the published road traffic injuries research in India, post-1990

BACKGROUND

Globally, road traffic injuries are the leading cause of death among those aged 15-29 years. However, road traffic injury research has not received adequate attention from the scientific community in low- and middle-income countries, including India. The present study aims to provide a bibliometric overview of research assessing road traffic injuries in India.

METHODS

We used Scopus to extract relevant research in road traffic injuries published from 1991 to 2017. This study presented the key bibliometric indicators such as trends of annual publications and citations, top 10 authors, journals, institutions and highly cited articles, citation analysis of articles, co-occurrence of keywords, etc. Analysis was performed using Scopus, Microsoft Excel, and VOS-viewer.

RESULTS

A total of 242 articles were retrieved with an h-index of 18, excluding self-citations. A steadfast growth of publications was documented in last decade, especially after the year 2010. The h-index of the top 10 authors, institutions, journals and highly cited articles did not surpass single digits. A network visualisation map showed that 'traffic accident', 'male', 'adolescent' and 'child' were the most commonly encountered key terms. The prominent authors were Gururaj G, Dandona R, and Hyder AA, whereas the top journals were the Indian Journal of Forensic Medicine and Toxicology, Medico Legal Update, and the International Journal of Applied Engineering Research and top institutions were the All India Institute of Medical Sciences, New Delhi, the Indian Institute of Technology, Delhi, and the Administrative Staff College of India.

CONCLUSION

In India, road traffic injuries research is inadequate in quantity and quality, warranting greater attention from researchers and policy planners to address the burden of road traffic injuries.

Epidemiology of Pediatric Musculoskeletal Injuries and Their Pattern in a Tertiary Care Center of North India

BACKGROUND

Trauma is emerging as an epidemic and a leading cause of morbidity and mortality in children. Children <15 years of age comprise about 32.8% or about 1/3^rd of the total Indian population. In India, up to one fourth of hospital admissions and approximately 15% of deaths in children are due to injury. This study presents the epidemiology, various causes and pattern of musculoskeletal injuries in pediatric population of North India.

MATERIALS AND METHODS

This is an observational, prospective hospital-based study conducted in a tertiary care center of North India for 6 months from July to December 2016. All pediatric patients in the age group 0-15 years who presented to the orthopedic emergency and out patient department with a history of trauma were included in the study.

RESULTS

Children aged 6-15 years (58%) suffered more injuries than children under 5 years of age (42%). Male pediatric population (58.5%) had more musculoskeletal injuries as compared to female pediatric population of the same age group (41.5%) in both the groups. Urban pediatric population (68.78%) suffered more injuries as compared to rural population of the same age group. Right extremities were more commonly involved in both the age groups. Upper limb injuries (50.59% in 0-5 years age group and 47.42% in 6- 15 years age group) were most common followed by lower limb and pelvic injuries. Very few (2.9% in 0- 5 years age group and 4.8% in 6-15 years age group) patients sustained isolated spinal injuries. Out of the 3712 patients 59.40% of patients had a history of fall, followed by road traffic accident related injuries (32%). The most common injuries were superficial injuries i.e., abrasions and bruises. The second most common injury was cut or open wounds mostly seen on hand, forearm and legs.

CONCLUSION

The high incidence of pediatric trauma on roads and falls indicates the need for more supervision during playing and identification of specific risk factors for these injuries in our setting. Injuries in pediatric age group by and large is a preventable condition. Therefore, injury prevention in children should be a priority.

Does spending matters? Re-looking into various covariates associated with Out of Pocket Expenditure (OOPE) and catastrophic spending on accidental injury from NSSO 71st round data

BACKGROUND

Accidental Injury is a traumatic event which not only influences physical, psychological, and social wellbeing of the households but also exerts extensive financial burden on them. Despite the devastating economic burden of injuries, in India, there is limited data available on injury epidemiology. This paper aims to, first, examine the socio-economic differentials in Out of Pocket Expenditure (OOPE) on accidental injury; second, to look into the level of Catastrophic Health Expenditure (CHE) at different threshold levels; and last, to explore the adjusted effect of various socio-economic covariates on the level of CHE.

METHODS

Data was extracted from the key indicators of social consumption in India: Health, National Sample Survey Organisation (NSSO), conducted by the Government of India during January-June-2014. Logistic regression analysis was employed to analyse the various covariates of OOPE and CHE associated to accidental injury.

FINDINGS

Binary Logistic analysis has demonstrated a significant association between socioeconomic status of the households and the level of OOPE and CHE on accidental injury care. People who used private health services incurred 16 times higher odds of CHE than those who availed public facilities. The result shows that if the person is covered via any type of insurance, the odd of CHE was lower by about 28% than the uninsured. Longer duration of stay and death due to accidental injury was positively associated with higher level of OOPE. Economic status, nature of healthcare facility availed and regional affiliation significantly influence the level of OOPE and CHE.

CONCLUSION

Despite numerous efforts by the Central and State governments to reduce the financial burden of healthcare, large number of households are still paying a significant amount from their own pockets. There are huge differentials in cost for the treatment among public and private healthcare providers for accidental injury. It is expected that the findings would provide insights into the prevailing magnitude of accidental injuries in India, the profile of the population affected, and the level of OOPE among households.

Cost of Trauma Care in Secondary- and Tertiary-Care Public Sector Hospitals in North India

BACKGROUND

Several initiatives to provide trauma care, including ambulance services, creation of a network of trauma hospitals and insurance schemes for cashless treatment, are currently being implemented in India. However, lack of information on the cost of trauma care is an impediment to the evidence-based planning for such initiatives. In this study, we aim to bridge this gap in evidence by estimating the unit cost of an outpatient consultation, inpatient bed-day of hospitalization, surgical procedure and diagnostics for providing trauma care through secondary- and tertiary-level hospitals in India.

METHODS

We undertook an economic costing of trauma care in a secondary-care district hospital and a tertiary-level teaching and research hospital in North India. Cost analysis was undertaken using a health system perspective, employing a bottom-up costing methodology. Data on all resources-capital or recurrent-on delivery of trauma care during the period of April 2014 to March 2015 were collected. Standardized unit costs were estimated after adjusting for bed occupancy rates. Sensitivity analysis was performed to account for the uncertainties due to differences in prices and other assumptions.

RESULTS

The cost of trauma care in the tertiary care hospital was INR 9585 (US$147.4) per day-care consultation; INR 2470 (US$37.7) per bed-day hospitalization (excluding ICU), INR 12,905 (US$198.5) per bed day in ICU and INR 21,499 (US$330.8) per surgery. Similarly, in the secondary-care hospital, the cost of trauma care was INR 482 (US$7.4) per outpatient consultation, INR 791 (US$12.2) per bed day of hospitalization, INR 186 (US$2.9) per minor surgery and INR 6505 (US$100.1) per major surgery.

CONCLUSION

The estimates generated can be used for planning and managing trauma care services in India. The findings may also be used for undertaking future research in estimating the cost effectiveness of trauma care services or models of care.

The 2017 International Joint Working Group White Paper by INDUSEM, the Emergency Medicine Association and the Academic College of Emergency Experts on Establishing Standardized Regulations, Operational Mechanisms, and Accreditation Pathways for Education and Care Provided by the Prehospital Emergency Medical Service Systems in India

The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.

Comparison of trauma care systems in Asian countries: A systematic literature review

OBJECTIVE

The study aims to compare the trauma care systems in Asian countries.

METHODS

Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries.

RESULTS

A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry.

CONCLUSION

Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries.

Trauma care in India: A review of the literature

BACKGROUND

We reviewed the published literature related to prehospital and hospital trauma care in India to identify how trauma care is defined in the literature and what factors limit the delivery of appropriate trauma care. In summarizing the evidence and recommendations regarding trauma care, this review identifies essential research and development goals to address the burden of injury in India.

METHODS

A review of the literature was conducted between August 2014 and September 2014. The literature was sorted into 3 categories: prehospital care, hospital clinical care, and hospital administrative care. The characteristics of trauma care were explored using the Essential Trauma Care Project of the World Health Organization.

RESULTS

A total of 38 studies were included. Prehospital care lacked care provided at the scene of the injury, timely transport to a hospital, and transport via ambulance. With regard to hospital care, we found a lack of capabilities of basic clinical care, such as airway management, insertion of chest tubes, and efforts at resuscitation. There was a lack of administrative capabilities, including trauma data systems, trauma-specific training, quality improvement, and development of designated trauma teams.

CONCLUSION

The high rate of injury-related deaths and disabilities in India could be in part due to the absence of integrated and organized systems of trauma care. In the prehospital setting, a multisector approach must be implemented to address the training of emergency medical service providers and community members. Prehospital transport time can be decreased through improved communication and transport modalities. The Indian trauma care system could also be strengthened through hospital-based training programs and trauma response teams.

Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments

Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum.

METHODS

A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review.

RESULTS

A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease.

CONCLUSIONS

Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills. Wijesekera O , Reed A , Chastain PS , Biggs S , Clark EG , Kole T , Chakrapani AT , Ashish N , Rajhans P , Breaud AH , Jacquet GA . Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675-679.

Predicting outcome in traumatic brain injury: Sharing experience of pilot traumatic brain injury registry

Background:

A reliable prediction of outcome for the victims of traumatic brain injury (TBI) on admission is possible from concurrent data analysis from any systematic real-time registry.

Objective:

To determine the clinical relevance of the findings from our TBI registry to develop prognostic futuristic models with readily available traditional and novel predictors.

Materials and Methods:

Prospectively collected data using predesigned pro forma were analyzed from the first phase of a trauma registry from a South Indian Trauma Centre, compatible with computerized management system at electronic data entry and web data entry interface on demographics, clinical, management, and discharge status.

Statistical Analysis:

On univariate analysis, the variables with P < 0.15 were chosen for binary logistic model. On regression model, variables were selected with test of coefficient 0.001 and with Nagelkerke R² with alpha error of 5%.

Results:

From 337 cases, predominantly males from rural areas in their productive age, road traffic injuries accounted for two-thirds cases, one-fourths occurred during postmonsoon while two-wheeler was the most common prerequisite. Fifty percent of patients had moderate to severe brain injury; the most common finding was unconsciousness followed by vomiting, ear bleed, seizures, and traumatic amnesia. Fifteen percent required intracranial surgery. Patients with severe Glasgow coma scale score were 4.5 times likely to have the fatal outcome (P = 0.003). Other important clinical variables accountable for fatal outcomes were oral bleeds and cervical spine injury while imperative socio-demographic risk correlates were age and seasons.

Conclusion:

TBI registry helped us finding predictors of clinical relevance for the outcomes in victims of TBI in search of prognostic futuristic models in TBI victims.

The 2014 Academic College of Emergency Experts in India's Education Development Committee (EDC) White Paper on establishing an academic department of Emergency Medicine in India - Guidelines for Staffing, Infrastructure, Resources, Curriculum and Training

Emergency medicine services and training in Emergency Medicine (EM) has developed to a large extent in developed countries but its establishment is far from optimal in developing countries. In India, Medical Council of India (MCI) has taken great steps by notifying EM as a separate specialty and so far 20 medical colleges have already initiated 3-year training program in EM. However, there has been shortage of trained faculty, and ambiguity regarding curriculum, rotation policy, infrastructure, teachers’ eligibility qualifications and scheme of examination. Academic College of Emergency Experts in India (ACEE-India) has been a powerful advocate for developing Academic EM in India. The ACEE's Education Development Committee (EDC) was created to chalk out guidelines for staffing, infrastructure, resources, curriculum, and training which may be of help to the MCI and the National Board of Examinations (NBE) to set standards for starting 3-year training program in EM and develop the departments of EM as centers of quality education, research, and treatment across India. This paper has made an attempt to give recommendations so as to provide a uniform framework to the institutions, thus guiding them towards establishing an academic Department of EM for starting the 3-year training program in the specialty of EM.