STRENGTHENING THE PREVENTION AND
TREATMENT OF INJURIES GLOBALLY
GHANA
Holy Family Hospital, Berekum, Ghana
Komfo Anokye Teaching Hospital: Kumasi
Outline
• 1. Extent and nature of problem.
• 2. Injury prevention
• 3. Trauma care (care of the injured)
• 4. Surveillance
• 5. Conclusions
Burden of Injury: Deaths
•
Source: Injuries and Violence: The Facts,
WHO, 2010. Available from www.who.int
Injury-related Mortality Rates
(per 100, 000 population)
Source: www.who.int
Source: Injuries and Violence: The Facts, WHO, 2010. Available from www.who.int
Injury problem is getting worse
Source: Injuries and Violence: The Facts, WHO, 2010. Available from www.who.int
Disability
16% of all disabilities are injury related.
WHO budget
DALYs
WHO
budget
$4 billion
Communicable disease &
maternal, perinatal and
nutritional conditions
41%
85%
Non-communicable dis.
47%
14%
Injuries
12%
<1%
Lopez, The Lancet Nov 2008
Trends in Motor Vehicle Deaths:
USA
35
Deaths/100,000/yr
30
25
20
USA
15
10
Washington
State
5
0
1920
1940
1960
Source: Baker et al, Injury Fact Book, 1992; NHTSA, Traffic Safety Facts.
1980
2000 2012
Spectrum of Injury Control
Surveillance
Prevention
Pre-Hospital
Care
Hospital
Care
Acute care Rehabilitation
Outline
• 1. Extent and nature of problem.
• 2. Injury prevention
• 3. Trauma care (care of the injured)
• 4. Surveillance
• 5. Conclusions
INJURY PREVENTION:
A SCIENTIFIC FIELD
• Research into Risk Factors
• Programs to Target Risk Factors
• Evaluate Results
Injury Prevention
UNINTENTIONAL INJURY
Motor Vehicle Safety
Pedestrian Safety
Fire safety / burn prevention
Drowning Prevention
Household Safety
Occupational Safety
INTENTIONAL INJURY
Suicide Prevention
Violence Prevention
3 E’s
• Engineering
– E.g. smoke detectors, safety features in cars
• Enforcement (and legislation)
– E.g. laws against drunk driving or speeding
• Education: social marketing to promote safe
behaviors
– E.g. seat belt or helmet use.
Roadway
• Intersection
• Alignment
Vehicle
• Design
• Maintenance
Road Safety
Human Factors
• Alcohol
• Speeding
• Traffic Laws
• Seatbelts
• Vision
Roadway Infrastructure
Seattle
Monterrey, Mexico
Monterrey barrels
Decrease in deaths from crashes
into fixed objects.
Roadway
• Intersection
• Alignment
Vehicle
• Design
• Maintenance
Road Safety
Human Factors
• Overspeeding
• Traffic Laws
• Seatbelts
• Vision
• Alcohol
Side impact protection:
Before: situation
with no protection
Side impact standard
improvements
Use of side impact beams in doors:
Less intrusion = less injury.
Vehicle factors
Low availability of
safety related spare parts
•Tires
•Brake components
•Brake fluid
•Source: Injury Prev, 1999.
Roadway
• Intersection
• Alignment
Vehicle
• Design
• Maintenance
Road Safety
Human Factors
• Alcohol
• Speeding
• Traffic Laws
• Seatbelts
• Vision
Ghana Drunk Driving Study
• Random roadside breathalyzer
• Based on NHTSA methodology
• 722 drivers tested with breathalyzers
Source: Mock C, Asiamah G, Amegashie J. A random, roadside breathalyzer survey of alcohol
impaired driver in Ghana. J Crash Prevention and Injury Control, 2: 193 – 202, 2001.
Ghana Drunk Driving Study
• % with BAC > 0.1 gm% (e.g. drunk) – weekend, PM
– Ghana
(1997)
11%
– USA
(1973)
5%
(1996)
3%
(2007)
2%
– In Ghana (24 hour, 7 day per week averages)
• Bus drivers:
3% intoxicated
• Truck drivers:
8% intoxicated
Source: Mock C, Asiamah G, Amegashie J. A random, roadside breathalyzer survey of alcohol
impaired driver in Ghana. J Crash Prevention and Injury Control, 2: 193 – 202, 2001.
Pedestrian Safety
Over half of all who die from road traffic crashes
globally are vulnerable road users (VRU):
– Motorcyclists
– Bicyclists
– Pedestrians
Much smaller part of problem in high-income countries
Pedestrian behavior
Multiple road users
Occupational risks and social issues
Preventive measures
Use of space
Preventive measures
Priority to pedestrians
Traffic calming
Targeting risk factors: speed
Vehicle speed: a risk to all, especially vulnerable road users
Source: World Report on Road Traffic Injury Prevention, WHO, 2004.
Available from www.who.int
Research on vehicle speeds: 20,000 vehicles
8%
4%
0%
40
Speed limit of
50 km/hr
60
80
100
120
Speed (km/hr)
140
James Damsere-Derry,
Research officer, BRRI,
Kumasi, Ghana
UW Fogarty scholar
Advocacy: Newspapers, press conference, FM radio stations.
First time that “speed control” addressed as topic of talk radio.
Source: Damsere-Derry et al, Traffic Injury Prevention, 2007; Injury Control Safety Promotion, 2008.
Speed reducing interventions
Example: Traffic calming along Accra-Kumasi road:
2005: 2 locations - 2010: 10 locations
Speed table
Asphalted speed bump
Photos courtesy of James Damsere-Derry
Thermoplastic speed bump
Rubberized delineators
• Effectiveness:
– Suhum junction:
• Crashes decreased 35%
• Fatalities decreased by 55%
• “Now people in the towns along the roads are
demanding these.”
– Francis Afukaar, BRRI, Nov, 2010
Informal, locally made speed bump:
Kumasi – Sunyani road, May 2013
Injury Prevention
UNINTENTIONAL INJURY
Motor Vehicle Safety
Pedestrian Safety
Fire safety / burn prevention
Drowning Prevention
Household Safety
Occupational Safety
INTENTIONAL INJURY
Suicide Prevention
Violence Prevention
Outline
• 1. Extent and nature of problem.
• 2. Injury prevention
• 3. Trauma care (care of the injured)
• 4. Surveillance
• 5. Conclusions
Spectrum of Injury Control
Surveillance
Prevention
Pre-Hospital
Care
Hospital
Care
Acute care Rehabilitation
PERCENT OF MODERATELY SEVERELY INJURED
(Inj Sev Score 15-24) WHO DIE
Percent mortality
40
36
30
20
10
6
0
Seattle, USA
Ghana
Source: Trauma Outcomes in the Rural Developing World:
Comparison with an Urban Level I Trauma Center J Trauma, 1993
Permanent Disability
• Much injury-related disability is
from extremity injury.
– Example: Most (78%) of injuryrelated disabilities in Ghana are
due to extremity injuries.
• Amenable to improvements in:
– Orthopedic care
– Rehabilitation
Source: Disabil Rehabil, 2003
CHALLENGES AND GAPS
A. Human Resources:
Example: Surgeons per 100,000
USA
50
Latin America 7
Africa
0.5
B. Physical Resources
(supplies, equipment)
Shortages in many critical items,
even those that are low cost.
CHALLENGES AND GAPS
C. Organization and Administration
• Main hospital in Kumasi, Ghana:
– 2022 trauma admissions
• Prolonged time to emergency
surgery: average 12 hours
• Low utilization of:
– fluid and blood resuscitation
– airway equipment
– chest tubes
Source: London et al, J Trauma 2001
IMPROVEMENTS POSSIBLE
despite financial restrictions
GNP
Per capita
Health $
Per capita
High income (e.g. USA)
$40,000
$5,000
Middle income (Latin America)
$1,000 10,000
$50 - $500
< $900
$7 - $50
Low income (Africa)
Improving Existing Ambulance Systems
Monterrey, Mexico
Intervention:
•1. Increase number of ambulance stations
•(2 to 4).
•2. Improved in-service training.
Effect: Mortality of transported
trauma patients decreased:
8.2% to 4.7%.
Cost: 16% of EMS budget.
Source: J Trauma, 48: 119, 2000.
Where to Proceed?
Settings with no formal EMS
One option: Build on existing, less formal, systems.
Example: Ghana, commercial drivers.
•400 received first aid training.
•1 year follow-up: 61% had used the training
Airway management
Bleeding control
Splint application
Triage
Source: J Trauma 53: 90; 2002.
Before
2%
4%
1%
7%
After
21%
25%
10%
21%
Improving Prehospital Care
in Absence of Formal EMS
Northern Iraq and Cambodia, mine infested areas.
Intervention:
Two tier system instituted:
- 5000 lay first responders with 1st aid training.
- Paramedics with 450 hour formal training.
Effect: Mortality decreased: 40% to 9%.
Sources: Husum et al. J Trauma 54: 1188; 2003;
WHO: Strengthening Care for the Injured: 2010. .
Hospital based improvements
Khon Kaen, Thailand
Intervention:
Trauma QI Program
–
High rate of preventable deaths
• Correctable problems identified
–Inadequate resuscitation for shock
–Delayed surgery for head injuries
–
Corrective action
• Improve communication
• Senior staffing in ED
• Improved record keeping
Results
–
Mortality decreased:
• 6.1% to 4.4%
Source: Chadbunchachai et al,
J Med Assoc Thai, 2003
DCPP: Most cost effective interventions
Surgery at
district hospital
Basic ambulance
Lay first responders
Source: Lancet 2006; 367: 1193–208
WHO: Trauma Care
Prehospital
Facility based
Define basic essential services.
Options for optimizing
prehospital care
•TIER (LEVEL 1):
•First responders
•TIER (LEVEL) 2:
•Formal EMS (ambulances)
Working Group for Essential Trauma Care
• International Society of Surgery and
WHO
• GOALS:
– Define minimum essential
trauma care services.
– Define resources necessary
– Catalyze improvements in
trauma care in countries
worldwide
Essential Trauma Care meeting: WHO, Geneva, June, 2002
Global
Public
Health
Trauma
Surgery
Essential Trauma Care
11 essential services –
Rights of the Injured:
Brief examples
• Assure that obstructed
airways are opened
• Assure that bleeding
(external or internal) is
stopped
• Assure that potentially
disabling orthopedic
injuries are corrected
Inputs needed: Low income settings
• All rural clinics
caring for injured
persons:
• Capabilities (training
and equipment) for:
rapid basic first aid
At least one third of rural injured
cared for at such facilities.
Inputs needed: Low income settings
District Hospitals
• Capabilities for chest
tubes and airway
maintenance
• Minimum blood
transfusion capabilities
Inputs needed: Low income settings
Tertiary care hospitals
• Endotracheal intubation
in casualty ward
(emergency basis)
• Basic quality
improvement programs
Middle income setting
• Similar recommendations: but including items that
increase probability of successful outcome, but also
increase cost.
Translated into:
Arabic, French, Russian, Spanish,
Vietnamese;
Part planning guide:
MOHs, facilities
Part advocacy statement
Catalyzing Increased Attention to Trauma Care
India, April 2003 & February 2005
Ghana, June 2005
Mexico, March 2004
Vietnam, March 2005
Needs assessments as stimulus for action
Outline
• 1. Extent and nature of problem.
• 2. Injury prevention
• 3. Trauma care (care of the injured)
• 4. Surveillance
• 5. Conclusions
Spectrum of Injury Control
Surveillance
Prevention
Pre-Hospital
Care
Hospital
Care
Acute care Rehabilitation
DATA FROM GHANA
• Usual sources of data for injury:
– Police Crash Reports
– Vital Statistics
– Hospital Records
• Under-reporting in all of these sources
Example of Under-reporting in
Vital Statistics
KATH Mortuary
Trauma
Deaths/Year
• Existing mortuary data (1992-5)
• Mortuary interviews (1996-2000)
Mock, Abantanga, Quansah, et al. Bulletin WHO, 2002
70
633
Mortuary data: improvements
persisted, with no additional funding
1992-5
1996-2000
2006-2007
Adofo Koranteng, Research Officer, KATH
Injury
Deaths/Year
70
633
773
Outline
• 1. Extent and nature of problem.
• 2. Injury prevention
• 3. Trauma care (care of the injured)
• 4. Surveillance
• 5. Conclusions
Injury Prevention:
Who is involved
Public Health Practitioners
Epidemiologists
Clinicians
Pediatricians
Primary Care
Surgeons
Media and Advertising
Psychologists
Engineers
Teachers
Lawyers
Police
Government
Non-government
agencies
Victims and families
For all this work there is a
need to engage the public
The landmarks of political, economic, and social history are
the moments when some condition passed from the category
of the given into the category of the intolerable…the history
of public health might well be written as a record of
successive re-definings of the unacceptable.
G. Vickers. “What sets the goals of public health?”
Lancet, 1958
Justice Amegashie
Noble Appiah
James Damsere-Derry,
UW Fogarty scholar
Educational offerings
Epi 586: Principles of Injury Research and Prevention
Epi 539: Research and Evaluation Methods for Global Health
Graduate Certificate in Global Injury and Violence Prevention
Graduate Certificate in Global
Injury and Violence Prevention
http://depts.washington.edu/hiprc
Thank You
• Ghana: Robert
Quansah, Peter
Donkor
• Mexico: Martin
Hernandez, Carlos
Arreola
• Vietnam: Nguyen
Son, Nguyen Tu
• India: Manjul
Joshipura, Mathew
Varghese
• WHO: Etienne Krug,
Margie Peden
PERCENT OF ALL SERIOUSLY INJURED (ISS > 9) WHO DIE
80
Percent of injured patients
who expire
70
60
63
50
55
40
30
35
20
10
0
Seattle, USA
Source: Mock et al, J Trauma 1998
Monterrey, Mexico
Kumasi, Ghana