- Email: [email protected]
WITHDRAWN: The Road Traffic Injury Treatment Network in Mainland China
Accepted Manuscript The Road Traffic Injury Treatment Network in Mainland China Wang Zhengguo, Zhang Lianyang, Zhang Liang, Zhao Wenjun PII:
S1008-1275(16)30025-6
DOI:
10.1016/j.cjtee.2016.02.006
Reference:
CJTEE 198
To appear in:
Chinese Journal of Traumatology
Received Date: 14 February 2016 Accepted Date: 16 February 2016
Please cite this article as: Zhengguo W, Lianyang Z, Liang Z, Wenjun Z, The Road Traffic Injury Treatment Network in Mainland China, Chinese Journal of Traumatology (2017), doi: 10.1016/ j.cjtee.2016.02.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
THE ROAD TRAFFIC INJURY TREATMENT NETWORK IN MAINLAND CHINA Wang Zhengguo, Zhang Lianyang, Zhang Liang, Zhao Wenjun Institute of Surgery, Daping Hospital, Third Military University, Chongqing, China
RI PT
Address correspondence to: Zhao Wenjun, No.10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China. E-mail: [email protected]
Mainland China is striving to transition from a developing country to an advanced and developed
SC
society. Although China’s economy has achieved extraordinary growth over the past three decades, many supporting facilities are still lagging behind. In terms of road traffic, on the one hand, the number
M AN U
of vehicles is growing rapidly (for example, the total number of vehicles rose to 240 million in 2012, quadrupling the number in 2000). On the other hand, compared with developed countries, the number of road traffic accidents and associated casualties still remains high and shows no signs of meaningful decline, largely resulted from deficiencies in traffic management, lack of corresponding legislation, and underdeveloped traffic safety awareness among the general public.
TE D
The number of road traffic causalities in China ranks highest in the world, with an annual death toll exceeding 100,000 and an average daily death toll of 300 [1]. These statistics demonstrate traffic accidents and causalities are still not curbed effectively in China even though significant efforts have been made. Therefore, it is a critical step to build up a China specific road traffic injury treatment
EP
network in order to reduce the fatality and disability rate. This article intends to review China’s road traffic injury treatment system and discuss how to improve traffic safety in the future. Pre-hospital rescue system for traffic injury
AC C
1.
To improve the efficiency of pre-hospital treatment, the key lies in shortening the reaction time,
which calls to establish a multi-level treatment system in each region. In China, the trauma treatment system is built upon regional emergency centers and 120 emergency calls. The city level rescue systems are generally well-established, comprising of independent emergency centers or emergency departments affiliated with large hospitals. Most of county-level trauma treatment systems rely on county hospitals, while rural areas on first-aid stations, to provide pre-hospital treatment [2]. As an example, by leveraging the pre-existing township hospitals and village clinics, “the traffic injury rescue project”, carried out by Jiangsu Province since 1992, has built up Red Cross rescue stations, distributed 1
ACCEPTED MANUSCRIPT emergency treatment equipment and trained volunteers, establishing a network of over 1,000 rescue points almost every five kilometers along the national and provincial highway. This project has played a great role in improving traffic injury treatment under the approach of “building a network by connecting the dots”.
RI PT
1.2 Standardization of pre-hospital treatment unit China’s Ministry of Health issued “Guidelines for Establishing and Managing Emergency Department” which requires the following: 1) sound pre-hospital rescue regulations which cover rescuer’s responsibilities, on-site rescue principles, duty shift regulations, and feedback reporting
SC
system; 2) a professional team for pre-hospital care with appropriate staff composition; 3) adequate emergency aid medicine and equipment, a convenient green channel to ensure efficient emergency
M AN U
patient admission, inspection and treatment as well as rapid placement of doctors from various departments; 4) simulative drills for emergency treatment once or twice a year. There are three emergency calling systems in China, namely 122 (traffic accidents), 110 (criminal related services), 119 (firefighting services). Trauma emergency treatment relies on telephone number 120 and telecommunication networks with 119 and 110 systems as backups when necessary. As an example, in
TE D
February 2010, the traffic police and the patrol police were merged by Chongqing government to be responsible for both criminal related services and traffic management with telephone numbers 119, 110, and 122 printed on the back of the patrol cars. These police cars patrol 24 hours a day and can respond
accident rescue.
EP
to any calls within 3 minutes. All these measures have significantly improved the efficiency of traffic
AC C
1.3 Guidelines for on-site rescue The treatment must be delivered as soon as possible. The fundamental principles include on-site
assessment of patients’ condition, assurance of basic life support as well as safe and rapid patient transfer. In particular, attention is needed in the following areas: (1) transfer of the patients to a safe location; (2) ABC (i.e. Airway clearance, Breathing and Circulation maintenance) rule for emergency treatment; (3) other treatment including evaluation of damage to the nerve system and the whole body, etc. Some scholars proposed to move life-saving surgical procedures to the accident scene in order to deliver precise treatment within the least amount of time. When encountering a large number of wounded personnel, the treatment process should follow “lifesaving first, injury treatment second; serious injury first, minor injury second; transferring patients to safe location first, injury treatment 2
ACCEPTED MANUSCRIPT second; patient transfer and injury treatment going hand-in-hand”. The seriously injured patients should ideally be treated within 10 minute after being injured before being triaged and transferred. The medical staff should focus on patient rescue. The speed of transferring patients after the on-site treatment could be improved with the establishment of small, multi-functional and highly mobile
RI PT
medical unit [1]. Connecting with the corresponding medical treatment organization should go hand-in-hand with on-site patient treatment to ensure rapid patient transfer [4]. Safety and rapidness is the basis of pre-hospital transferring. Once the patients’ condition is stabilized, they should be transferred to the
SC
nearest and most suitable medical unit according to a prioritized order. Ambulances are the main patient transferring vehicles in China. Based on the Ministry of Health’s requirements, Shenzhen
M AN U
municipal government published “Guidelines for establishing Shenzhen emergency hospital network” which requests that every hospital within the network establish a pre-hospital emergency department with a 3-member pre-hospital emergency team (including a doctor, a nurse and a driver). The emergency vehicle and the driver are explicitly assigned to be part of the emergency department. In Qingdao, Shandong Province, in order to improve effectiveness of the emergency network, the city
TE D
government integrated different resources to standardize the emergency treatment network consisting of personnel, documentation, vehicles, information, accounting systems and so on. Since 1992, 5,000 to 10,000 km of expressway is constructed every year in China. In 2011, the
EP
total expressway mileage in China has exceeded 100,000 km, ranked number one in the world. Accompanied with the rapid development of the expressway system, the number of road traffic
AC C
accidents is increasing at an alarming rate. For example, during the 4 years after the construction of Shenyang-Dalian expressway, the death toll from traffic accidents was 376 with a 69.7% on-site fatality rate and another 6.6% fatality rate during patient transfer [5]. At China’s national level, the number of traffic accidents, the total death toll and the fatality rate are still higher than those in developed countries [6]. The characteristics of expressway injuries are high occurrences of multiple injuries, high death toll and high fatality rate, highlighting the importance of constructing an effective expressway traffic injury treatment system. China’s expressway rescue system has experienced noticeable improvement over the past 20 years, including faster accident reporting and shortened response time after receiving the emergency call. As an example, located at the Humen exit on Guangzhou-Shenzhen expressway, the emergency trauma treatment center, established by Dongguan city government of 3
ACCEPTED MANUSCRIPT Guangdong Province, has treated 1,726 severe trauma cases and conducted 1,921 emergency surgeries with 98.1% success rate in a period of five years. The treatment center attributes its success to close coordination between the police and the medical team for rapid response, between the medical team and the ambulance/transportation team for high mobility, and between on-site medical team and the
1.4 Challenges in pre-hospital rescue system
RI PT
hospital for smooth transition.
China’s road injury pre-hospital treatment system varies greatly across regions, mainly resulted from differences in regional cultures, economic development, and status of local infrastructure. These
SC
differences have led to issues such as 1) non-standardized pre-hospital treatment system, deficient emergency treatment network, prolonged accident response time; 2) shortage of emergency rescue staff;
M AN U
3) non-standardized pre-hospital rescue unit and associated transportation vehicle/ambulance. Traffic accident death rate in rural areas is three to four times higher than that in urban regions because the 120 emergency calling system is limited to the urban areas and transferring of patients from accident scenes is mainly conducted on passing-by vehicles. For example, the rate of patient transfer by ambulance is just 15.7% in Shaanxi [7] and 17.6% in Shenyang [5]. It is still necessary to improve the efficiency and
purpose.
Current status of in-hospital traffic injury treatment
EP
2.
TE D
safety of pre-hospital patient transfer as most regions in China intend to use ambulances for this
While there is no universal in-hospital trauma treatment protocol in China, majority of the
AC C
general hospitals use specialist consultation to treat trauma patients. The two dominant mechanisms are (1) Cross-department consultation coupled with serial treatment process: The emergency
department is responsible for organizing a cross-department team to evaluate the trauma patients, which is then followed by a serial treatment process conducted by the emergency department, operational specialists, ICU, etc. This treatment mechanism is adopted by most general hospitals. (2) Integrated process: The specialized surgical department or similar emergency department is responsible for the patient’s early stage in-hospital treatment, follow-on operations and monitoring. This process has demonstrated noticeable advantages in treating multiple injuries and in resuscitative surgeries. In recent years, an increasing number of specialized trauma treatment centers have been established in China, leading to a higher rescue rate because of more available human and material 4
ACCEPTED MANUSCRIPT resources as well as more experienced personnel [8]. For example, the trauma treatment center of Daping Hospital at the Third Military University consists of Emergency Center, Traumatology Department, ICU, Rehabilitation Department, etc. This arrangement, supported by more systematic and specially designed processes, enables a tight integration between pre-hospital rescue and in-hospital
RI PT
treatment [9]. The level of in-hospital trauma treatment is therefore significantly improved. The emergency department is the first stop for in-hospital trauma treatment and even undertakes emergency surgeries in some hospitals. The first step of the treatment procedure is to apply critical life support, followed by a thorough evaluation of the injured patient, signing the letter of consent, and then
SC
transferring the patient to Radiology Department and the operating room. Evaluating and treating trauma injuries is both urgency and complex. In order to improve treatment efficiency, some scholars
M AN U
have proposed an emergency treatment responsibility model called ABCDEF (Figure 1): a nurse at point A stands by the side of the patient’s head, responsible for the patient’s airway; a doctor at point B stands by the patient’s right-hand side, responsible for CPR and managing the patient monitoring devices; a nurse at point C stands by the left-hand side of the patient, responsible for the patient’s circulatory system and monitoring the patient’s vital signs; a nurse at point D stands by the patient’s
TE D
right leg, responsible for recording the treatment process; the attending doctor stands by the patient’s left leg, responsible for directing and coordinating the overall rescue procedure [10]. The importance of traumatology lies in two aspects: definitive assessment of trauma injuries
EP
within the treatment’s golden window and application of integrated cross-disciplinary treatment to the multiple injuries [11]. At China’s Third Military University’s Daping Hospital Trauma Treatment
AC C
Center, the traumatology staff includes specialists and technicians from many departments such as Department of General Surgery, Department of Cerebral Surgery, Department of Orthopedics, and Department of Neurosurgery. The center has 95 beds and treats all trauma injuries except those on eyes, ears, nose and face. The center has also established standard clinical procedures for treating patients with severe trauma injuries, only admitting patients with pre-hospital index (PHI) above 4 or with penetrating wounds on chest, stomach, etc. From January 2006 to December 2010, the center had treated 204 severe trauma injury cases, accounting for 4.23% of the total trauma patients. The time from admission to definitive surgery is significantly shortened with a 92.87% rescue success rate [12]. In 2011, Guilin No. 181 hospital and Guilin municipal traffic management division co-founded “the lifesaving green traffic channel”. Two 24-hour emergency centers were established at urban-rural 5
ACCEPTED MANUSCRIPT transition areas in Guilin. Doctors on duty at the emergency centers can be notified immediately when the traffic police receive reports of a traffic accident. Emergency rescue personnel will be sent to the traffic scene and then transfer the patients to the nearest hospital. Standard communication procedures have also been established among the emergency rescue team, the hospital trauma treatment center and
RI PT
the Guilin emergency call center [13]. From January 2005 to December 2007, the No. 181 hospital had treated 5,745 cases of traffic injury, including 1,534 cases of brain injury (27.2%), 1,094 cases of chest injury (19.4%), 541 cases of abdominal trauma (9.6%), and 3,159 cases of limb and spinal injury (56.0%). Among all the injuries, 1,422 cases were severe multiple injuries (25.2%) where a successful
SC
rescue rate of 98.2% was achieved. There were also 104 deaths (1.8%). [14]. Conclusion
M AN U
Improving traffic injury treatment requires a systematic approach and coordinated efforts from many parties in the society. After all, the medical emergency treatment is the last link of the 5E strategy (education, environment, enforcement, engineering, and emergency). The key to improving the rescue success rate is to deliver definitive treatment to the patient in the golden window and to enhance the pre-hospital and in-hospital treatment capabilities. It is also recommended to unify various pre-hospital
TE D
and in-hospital treatment protocols in China based on field experience [15]. Other critical areas for improving traffic injury treatment include to establish a national level treatment system closely linked to the 120 emergency call system, to use helicopters as the main aerial transport vehicles, to set up
EP
state-level training centers for trauma treatment, to build national and regional traffic injury database,
AC C
and to formulate standards to qualify trauma treatment hospitals and doctors.
References
[1] Yue MX, Liu ZG, Cai XQ, et al. The characteristics of road traffic injuries and a new concept for on-site emergency rescue. Chin Gen Prac, 2004, 7(24): 1803-1805. [2] Wang YT. Current status and future prospects for China’s pre-hospital rescue of traffic injury. J Trauma Surg, 2000, 2(1): 5-6. [3] Zhou JH, Wang ZG. Progress in traffic injury research in China. Chin J Traumatol, 2005, 21(1): 71-73. [4] Zhang LY, Yao YZ. Early treatment for severe trauma. Chin Gen Pract Surg, 2008, 28(7): 582-584. [5] Li JG, Zheng LG, Shi JP. Preliminary reports on vertebral column injuries induced by highway 6
ACCEPTED MANUSCRIPT traffic accidents. Chin J Emerg Med, 1988, 7: 418-419. [6] Gao JD, Cheng F.
Current status of highway traffic injury and pre-hospital rescue in China. Chin
Gen Pract Surg, 2004, 18(4): 365-367. [7] Gao JD, Zong T, Chang XD. Current status and treatment strategies for highway traffic injuries in
RI PT
Shaanxi. Chin J Emerg Med, 2004; 13: 135-136. [8] Wen L, Liu MH, Xiong JQ, et al. Investigation of emergency trauma treatment mechanisms. Chin J Crit Care Med, 2005; 25(1): 41-43.
[9] Zhang LY. Promote the core competency of specialized trauma hospitals. Hosp Adm J PLA, 2010,
SC
17(2): 107-109.
[10] Zhou BZ, Zhang SY. Emergency treatment procedures for severe multiple traffic accident injuries.
M AN U
Clin Educ Gen Pract, 2008, 6(2), 127-129.
[11] Gan JX, Shen WF. Current issues and future direction for trauma treatment models. Chin J Traumatol, 2006, 22(9): 641-643.
[12] Yao YZ, Sun SJ, Tan H, et al. Discussions on time efficiency of in-hospital severe trauma treatment. J Trauma Surg, 2011, 13(2): 103-106.
TE D
[13] Kong ZB, Liu J, Liu X. New model of pre-hospital first aid for severe traffic accidents in urban-suburb transition area. Milit Med J
South Chin, 2008, 22(4): 56-57.
[14] Kong ZB, Liu J, Liu X, et al. A new model of pre-hospital traffic accident emergency rescue. Peop Milit Surg , 2009, 52(7): 449-450.
AC C
455-458.
EP
[15] Wang ZG. Research and reflections on road traffic injury. Acute Acad Med Sci, 2007, 29(4):
1.1 Three main types of pre-hospital rescue control center
Table 1: Types of pre-hospital rescue center [3] Type
Typical
Characteristics
Advantages
Disadvantages
location
Authoritative Command
Beijing, Guangzhou
No emergency department, no
Small
Challenges in ensuring
direct administrative relationship,
investment, fully
pre-hospital care quality
but has authority to command other
leverage existing
when coordinating different
hospitals in providing pre-hospital
facilities
hospitals
7
ACCEPTED MANUSCRIPT care Affiliated with a general hospital as
Small investment,
an internal department, directed by
strong ability to
the hospital and health
handle
administrative agency, with
pre-hospital
emergency center in the emergency
rescue, effective
department
cross-department
Hospital
Difficult to coordinate with Chongqing
other hospitals
RI PT
Affiliation
treatment
SC
Properly
designed with
With its own pre-hospital care
rescue coverage,
Difficult in maintaining
center and branch stations
fully leverage
effective command center
responsible for pre-hospital rescue,
existing
due to possible high
in-hospital treatment conducted by
in-hospital
personnel turnover resulted
partner hospitals
resources, ease to
from unchallenging work
Cooperative Shanghai
M AN U
effective regional
EP
TE D
Command
ensure smooth treatment processes
AC C
Figure 1: Emergency rescue personnel responsibility assignment model
8
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
9
S1008-1275(16)30025-6
DOI:
10.1016/j.cjtee.2016.02.006
Reference:
CJTEE 198
To appear in:
Chinese Journal of Traumatology
Received Date: 14 February 2016 Accepted Date: 16 February 2016
Please cite this article as: Zhengguo W, Lianyang Z, Liang Z, Wenjun Z, The Road Traffic Injury Treatment Network in Mainland China, Chinese Journal of Traumatology (2017), doi: 10.1016/ j.cjtee.2016.02.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
THE ROAD TRAFFIC INJURY TREATMENT NETWORK IN MAINLAND CHINA Wang Zhengguo, Zhang Lianyang, Zhang Liang, Zhao Wenjun Institute of Surgery, Daping Hospital, Third Military University, Chongqing, China
RI PT
Address correspondence to: Zhao Wenjun, No.10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China. E-mail: [email protected]
Mainland China is striving to transition from a developing country to an advanced and developed
SC
society. Although China’s economy has achieved extraordinary growth over the past three decades, many supporting facilities are still lagging behind. In terms of road traffic, on the one hand, the number
M AN U
of vehicles is growing rapidly (for example, the total number of vehicles rose to 240 million in 2012, quadrupling the number in 2000). On the other hand, compared with developed countries, the number of road traffic accidents and associated casualties still remains high and shows no signs of meaningful decline, largely resulted from deficiencies in traffic management, lack of corresponding legislation, and underdeveloped traffic safety awareness among the general public.
TE D
The number of road traffic causalities in China ranks highest in the world, with an annual death toll exceeding 100,000 and an average daily death toll of 300 [1]. These statistics demonstrate traffic accidents and causalities are still not curbed effectively in China even though significant efforts have been made. Therefore, it is a critical step to build up a China specific road traffic injury treatment
EP
network in order to reduce the fatality and disability rate. This article intends to review China’s road traffic injury treatment system and discuss how to improve traffic safety in the future. Pre-hospital rescue system for traffic injury
AC C
1.
To improve the efficiency of pre-hospital treatment, the key lies in shortening the reaction time,
which calls to establish a multi-level treatment system in each region. In China, the trauma treatment system is built upon regional emergency centers and 120 emergency calls. The city level rescue systems are generally well-established, comprising of independent emergency centers or emergency departments affiliated with large hospitals. Most of county-level trauma treatment systems rely on county hospitals, while rural areas on first-aid stations, to provide pre-hospital treatment [2]. As an example, by leveraging the pre-existing township hospitals and village clinics, “the traffic injury rescue project”, carried out by Jiangsu Province since 1992, has built up Red Cross rescue stations, distributed 1
ACCEPTED MANUSCRIPT emergency treatment equipment and trained volunteers, establishing a network of over 1,000 rescue points almost every five kilometers along the national and provincial highway. This project has played a great role in improving traffic injury treatment under the approach of “building a network by connecting the dots”.
RI PT
1.2 Standardization of pre-hospital treatment unit China’s Ministry of Health issued “Guidelines for Establishing and Managing Emergency Department” which requires the following: 1) sound pre-hospital rescue regulations which cover rescuer’s responsibilities, on-site rescue principles, duty shift regulations, and feedback reporting
SC
system; 2) a professional team for pre-hospital care with appropriate staff composition; 3) adequate emergency aid medicine and equipment, a convenient green channel to ensure efficient emergency
M AN U
patient admission, inspection and treatment as well as rapid placement of doctors from various departments; 4) simulative drills for emergency treatment once or twice a year. There are three emergency calling systems in China, namely 122 (traffic accidents), 110 (criminal related services), 119 (firefighting services). Trauma emergency treatment relies on telephone number 120 and telecommunication networks with 119 and 110 systems as backups when necessary. As an example, in
TE D
February 2010, the traffic police and the patrol police were merged by Chongqing government to be responsible for both criminal related services and traffic management with telephone numbers 119, 110, and 122 printed on the back of the patrol cars. These police cars patrol 24 hours a day and can respond
accident rescue.
EP
to any calls within 3 minutes. All these measures have significantly improved the efficiency of traffic
AC C
1.3 Guidelines for on-site rescue The treatment must be delivered as soon as possible. The fundamental principles include on-site
assessment of patients’ condition, assurance of basic life support as well as safe and rapid patient transfer. In particular, attention is needed in the following areas: (1) transfer of the patients to a safe location; (2) ABC (i.e. Airway clearance, Breathing and Circulation maintenance) rule for emergency treatment; (3) other treatment including evaluation of damage to the nerve system and the whole body, etc. Some scholars proposed to move life-saving surgical procedures to the accident scene in order to deliver precise treatment within the least amount of time. When encountering a large number of wounded personnel, the treatment process should follow “lifesaving first, injury treatment second; serious injury first, minor injury second; transferring patients to safe location first, injury treatment 2
ACCEPTED MANUSCRIPT second; patient transfer and injury treatment going hand-in-hand”. The seriously injured patients should ideally be treated within 10 minute after being injured before being triaged and transferred. The medical staff should focus on patient rescue. The speed of transferring patients after the on-site treatment could be improved with the establishment of small, multi-functional and highly mobile
RI PT
medical unit [1]. Connecting with the corresponding medical treatment organization should go hand-in-hand with on-site patient treatment to ensure rapid patient transfer [4]. Safety and rapidness is the basis of pre-hospital transferring. Once the patients’ condition is stabilized, they should be transferred to the
SC
nearest and most suitable medical unit according to a prioritized order. Ambulances are the main patient transferring vehicles in China. Based on the Ministry of Health’s requirements, Shenzhen
M AN U
municipal government published “Guidelines for establishing Shenzhen emergency hospital network” which requests that every hospital within the network establish a pre-hospital emergency department with a 3-member pre-hospital emergency team (including a doctor, a nurse and a driver). The emergency vehicle and the driver are explicitly assigned to be part of the emergency department. In Qingdao, Shandong Province, in order to improve effectiveness of the emergency network, the city
TE D
government integrated different resources to standardize the emergency treatment network consisting of personnel, documentation, vehicles, information, accounting systems and so on. Since 1992, 5,000 to 10,000 km of expressway is constructed every year in China. In 2011, the
EP
total expressway mileage in China has exceeded 100,000 km, ranked number one in the world. Accompanied with the rapid development of the expressway system, the number of road traffic
AC C
accidents is increasing at an alarming rate. For example, during the 4 years after the construction of Shenyang-Dalian expressway, the death toll from traffic accidents was 376 with a 69.7% on-site fatality rate and another 6.6% fatality rate during patient transfer [5]. At China’s national level, the number of traffic accidents, the total death toll and the fatality rate are still higher than those in developed countries [6]. The characteristics of expressway injuries are high occurrences of multiple injuries, high death toll and high fatality rate, highlighting the importance of constructing an effective expressway traffic injury treatment system. China’s expressway rescue system has experienced noticeable improvement over the past 20 years, including faster accident reporting and shortened response time after receiving the emergency call. As an example, located at the Humen exit on Guangzhou-Shenzhen expressway, the emergency trauma treatment center, established by Dongguan city government of 3
ACCEPTED MANUSCRIPT Guangdong Province, has treated 1,726 severe trauma cases and conducted 1,921 emergency surgeries with 98.1% success rate in a period of five years. The treatment center attributes its success to close coordination between the police and the medical team for rapid response, between the medical team and the ambulance/transportation team for high mobility, and between on-site medical team and the
1.4 Challenges in pre-hospital rescue system
RI PT
hospital for smooth transition.
China’s road injury pre-hospital treatment system varies greatly across regions, mainly resulted from differences in regional cultures, economic development, and status of local infrastructure. These
SC
differences have led to issues such as 1) non-standardized pre-hospital treatment system, deficient emergency treatment network, prolonged accident response time; 2) shortage of emergency rescue staff;
M AN U
3) non-standardized pre-hospital rescue unit and associated transportation vehicle/ambulance. Traffic accident death rate in rural areas is three to four times higher than that in urban regions because the 120 emergency calling system is limited to the urban areas and transferring of patients from accident scenes is mainly conducted on passing-by vehicles. For example, the rate of patient transfer by ambulance is just 15.7% in Shaanxi [7] and 17.6% in Shenyang [5]. It is still necessary to improve the efficiency and
purpose.
Current status of in-hospital traffic injury treatment
EP
2.
TE D
safety of pre-hospital patient transfer as most regions in China intend to use ambulances for this
While there is no universal in-hospital trauma treatment protocol in China, majority of the
AC C
general hospitals use specialist consultation to treat trauma patients. The two dominant mechanisms are (1) Cross-department consultation coupled with serial treatment process: The emergency
department is responsible for organizing a cross-department team to evaluate the trauma patients, which is then followed by a serial treatment process conducted by the emergency department, operational specialists, ICU, etc. This treatment mechanism is adopted by most general hospitals. (2) Integrated process: The specialized surgical department or similar emergency department is responsible for the patient’s early stage in-hospital treatment, follow-on operations and monitoring. This process has demonstrated noticeable advantages in treating multiple injuries and in resuscitative surgeries. In recent years, an increasing number of specialized trauma treatment centers have been established in China, leading to a higher rescue rate because of more available human and material 4
ACCEPTED MANUSCRIPT resources as well as more experienced personnel [8]. For example, the trauma treatment center of Daping Hospital at the Third Military University consists of Emergency Center, Traumatology Department, ICU, Rehabilitation Department, etc. This arrangement, supported by more systematic and specially designed processes, enables a tight integration between pre-hospital rescue and in-hospital
RI PT
treatment [9]. The level of in-hospital trauma treatment is therefore significantly improved. The emergency department is the first stop for in-hospital trauma treatment and even undertakes emergency surgeries in some hospitals. The first step of the treatment procedure is to apply critical life support, followed by a thorough evaluation of the injured patient, signing the letter of consent, and then
SC
transferring the patient to Radiology Department and the operating room. Evaluating and treating trauma injuries is both urgency and complex. In order to improve treatment efficiency, some scholars
M AN U
have proposed an emergency treatment responsibility model called ABCDEF (Figure 1): a nurse at point A stands by the side of the patient’s head, responsible for the patient’s airway; a doctor at point B stands by the patient’s right-hand side, responsible for CPR and managing the patient monitoring devices; a nurse at point C stands by the left-hand side of the patient, responsible for the patient’s circulatory system and monitoring the patient’s vital signs; a nurse at point D stands by the patient’s
TE D
right leg, responsible for recording the treatment process; the attending doctor stands by the patient’s left leg, responsible for directing and coordinating the overall rescue procedure [10]. The importance of traumatology lies in two aspects: definitive assessment of trauma injuries
EP
within the treatment’s golden window and application of integrated cross-disciplinary treatment to the multiple injuries [11]. At China’s Third Military University’s Daping Hospital Trauma Treatment
AC C
Center, the traumatology staff includes specialists and technicians from many departments such as Department of General Surgery, Department of Cerebral Surgery, Department of Orthopedics, and Department of Neurosurgery. The center has 95 beds and treats all trauma injuries except those on eyes, ears, nose and face. The center has also established standard clinical procedures for treating patients with severe trauma injuries, only admitting patients with pre-hospital index (PHI) above 4 or with penetrating wounds on chest, stomach, etc. From January 2006 to December 2010, the center had treated 204 severe trauma injury cases, accounting for 4.23% of the total trauma patients. The time from admission to definitive surgery is significantly shortened with a 92.87% rescue success rate [12]. In 2011, Guilin No. 181 hospital and Guilin municipal traffic management division co-founded “the lifesaving green traffic channel”. Two 24-hour emergency centers were established at urban-rural 5
ACCEPTED MANUSCRIPT transition areas in Guilin. Doctors on duty at the emergency centers can be notified immediately when the traffic police receive reports of a traffic accident. Emergency rescue personnel will be sent to the traffic scene and then transfer the patients to the nearest hospital. Standard communication procedures have also been established among the emergency rescue team, the hospital trauma treatment center and
RI PT
the Guilin emergency call center [13]. From January 2005 to December 2007, the No. 181 hospital had treated 5,745 cases of traffic injury, including 1,534 cases of brain injury (27.2%), 1,094 cases of chest injury (19.4%), 541 cases of abdominal trauma (9.6%), and 3,159 cases of limb and spinal injury (56.0%). Among all the injuries, 1,422 cases were severe multiple injuries (25.2%) where a successful
SC
rescue rate of 98.2% was achieved. There were also 104 deaths (1.8%). [14]. Conclusion
M AN U
Improving traffic injury treatment requires a systematic approach and coordinated efforts from many parties in the society. After all, the medical emergency treatment is the last link of the 5E strategy (education, environment, enforcement, engineering, and emergency). The key to improving the rescue success rate is to deliver definitive treatment to the patient in the golden window and to enhance the pre-hospital and in-hospital treatment capabilities. It is also recommended to unify various pre-hospital
TE D
and in-hospital treatment protocols in China based on field experience [15]. Other critical areas for improving traffic injury treatment include to establish a national level treatment system closely linked to the 120 emergency call system, to use helicopters as the main aerial transport vehicles, to set up
EP
state-level training centers for trauma treatment, to build national and regional traffic injury database,
AC C
and to formulate standards to qualify trauma treatment hospitals and doctors.
References
[1] Yue MX, Liu ZG, Cai XQ, et al. The characteristics of road traffic injuries and a new concept for on-site emergency rescue. Chin Gen Prac, 2004, 7(24): 1803-1805. [2] Wang YT. Current status and future prospects for China’s pre-hospital rescue of traffic injury. J Trauma Surg, 2000, 2(1): 5-6. [3] Zhou JH, Wang ZG. Progress in traffic injury research in China. Chin J Traumatol, 2005, 21(1): 71-73. [4] Zhang LY, Yao YZ. Early treatment for severe trauma. Chin Gen Pract Surg, 2008, 28(7): 582-584. [5] Li JG, Zheng LG, Shi JP. Preliminary reports on vertebral column injuries induced by highway 6
ACCEPTED MANUSCRIPT traffic accidents. Chin J Emerg Med, 1988, 7: 418-419. [6] Gao JD, Cheng F.
Current status of highway traffic injury and pre-hospital rescue in China. Chin
Gen Pract Surg, 2004, 18(4): 365-367. [7] Gao JD, Zong T, Chang XD. Current status and treatment strategies for highway traffic injuries in
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Shaanxi. Chin J Emerg Med, 2004; 13: 135-136. [8] Wen L, Liu MH, Xiong JQ, et al. Investigation of emergency trauma treatment mechanisms. Chin J Crit Care Med, 2005; 25(1): 41-43.
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[10] Zhou BZ, Zhang SY. Emergency treatment procedures for severe multiple traffic accident injuries.
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Clin Educ Gen Pract, 2008, 6(2), 127-129.
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[12] Yao YZ, Sun SJ, Tan H, et al. Discussions on time efficiency of in-hospital severe trauma treatment. J Trauma Surg, 2011, 13(2): 103-106.
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[13] Kong ZB, Liu J, Liu X. New model of pre-hospital first aid for severe traffic accidents in urban-suburb transition area. Milit Med J
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[15] Wang ZG. Research and reflections on road traffic injury. Acute Acad Med Sci, 2007, 29(4):
1.1 Three main types of pre-hospital rescue control center
Table 1: Types of pre-hospital rescue center [3] Type
Typical
Characteristics
Advantages
Disadvantages
location
Authoritative Command
Beijing, Guangzhou
No emergency department, no
Small
Challenges in ensuring
direct administrative relationship,
investment, fully
pre-hospital care quality
but has authority to command other
leverage existing
when coordinating different
hospitals in providing pre-hospital
facilities
hospitals
7
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Small investment,
an internal department, directed by
strong ability to
the hospital and health
handle
administrative agency, with
pre-hospital
emergency center in the emergency
rescue, effective
department
cross-department
Hospital
Difficult to coordinate with Chongqing
other hospitals
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Affiliation
treatment
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Properly
designed with
With its own pre-hospital care
rescue coverage,
Difficult in maintaining
center and branch stations
fully leverage
effective command center
responsible for pre-hospital rescue,
existing
due to possible high
in-hospital treatment conducted by
in-hospital
personnel turnover resulted
partner hospitals
resources, ease to
from unchallenging work
Cooperative Shanghai
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effective regional
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Command
ensure smooth treatment processes
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Figure 1: Emergency rescue personnel responsibility assignment model
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