Page 1 of 17 REPORT ON TRAUMA CENTER SIRSA BY- DR.JAIDEEP KUMAR MPH ON 8/8/2009What is Trauma?The word ‘trauma’ is derived from the Greek meaning ‘bodily injury’.What is Trauma Centre?Trauma centre is defined as a specialised hospital facility distinguished by the immediateavailability of specialised surgeons, physician specialists, anesthesiologists, nurses, andresuscitation and life support equipment on a 24-hour basis to care for severely injuredpatients or those at risk for severe injury.Magnitude of Trauma and Injuries:-Incidence of trauma is on the rise globally due to industrialization, urbanisation,increase in mechanised transport, urban violence, social conflicts, and man-made as wellas natural disasters. Trauma is a number one killer below 40 years leading to highmorbidity, mortality, disability and economic loss to the country.If current trendcontinues, road traffic injuries intentional injuries i.e. self inflicted injuries, interpersonalviolence and war related injuries will rank among the 15 leading causes of death andburden of disease. Road traffic injuries are a leading cause of death by injury accountingfor 20.3 per cent of all deaths from injury.It is 10th leading cause of all deaths, ninth leading contributor to the burden of diseaseworldwide. Deaths from injuries are projected to rise from 5.1 million at present to 8.4million by 2020. In India, 80, 000 persons got killed and 38 million persons got injureddue to road traffic accidents. In Armed Forces, approximately 20 persons per 1000population get admitted in the hospitals due to non-enemy action injuries per year. Indiahas 1% of the motor vehicles in the world, but bears the burden of 6% of the globalvehicular accidents. Road-traffic accidents are increasing at an alarming annual rate of
Page 2 of 173%. In 1997, 10.1% of all deaths in India were due to accidents and injuries. A vehicularaccident is reported every 3 minutes and a death every 10 minutes on Indian roads.During 1998, nearly 80,000 lives were lost and 330,000 people were injured. Of these,78% were men in age group of 20-44 years, causing significant impact on productivity.A trauma-related death occurs in India every 1.9 minutes. The majority of fatal road-traffic accident victims are pedestrians, two wheeler riders and bicyclists.India is a disaster-prone country with frequent floods, cyclones, landslides andearthquakes. Train accidents and industrial mishaps are not uncommon. Governmentplans are in place, in general, to deal with disasters. However, regular drills to testpreparedness are not carried out. Only 26% of the systems in the survey reported a well-documented disaster management plan. The rest of the systems have plans underdevelopment, or no plans. This deficiency has resulted in excessive numbers of deaths innatural disasters. In 1999, there was an increase of 20.8% in fatalities due to suchdisasters compared to the previous year. This figure for 2001 is likely to rise even furtheras a result of a killer earthquake in Gujarat, causing over 12,000 deaths.Why Trauma centre was developed?It is established that the mortality in serious injuries is six times worse in a developingcountry such as India compared to a developed country. The future appears both dauntingand challenging. It is estimated that from its present position of the ninth leading cause ofdeaths in India, trauma will move up to third position by 2020. It is also estimated that inthe developing countries over 6 million will die and 60 million will be injured, ordisabled, in the next 10 years. India will have a large share in this, with an estimatedeconomic loss of around 2% of GDP. To meet this challenge several efforts are required:resource creation, education, legislation, upgrading prehospital and hospital based care,public awareness and a change in the attitude of the policy-makers. The public healthinstitutions will also benefit from adopting WHO Essential Trauma Care guidelines fortrauma care, which is aimed at low cost improvements to the trauma care. There arealready some ongoing efforts in that direction.. Rapid urbanisation and industrialisation
Page 3 of 17have created an environment in which humans are continuously exposed to myriadhazards. An accident is rarely caused by a single factor rather a series of events coincidein time and space for the unfortunate event to occur. Last decade has witnessed aconsiderable increase in morbidity and mortality from the road accidents. Trauma is thethird major cause of death amongst all possible reasons after heart ailments and chestinfections. Most of the serious injuries resulting from traffic accidents are related to head,spine at internal vital organs. In accidents 50% of the victims have serious injuries tocardiovascular or central nervous system and die in the first 15 minutes.Of the rest ,basiclife support,first –aid and replacement of fluid,if arranged within the first hours of injury(golden hour) can save many lives. 35% die within next 1-2 hours due to head and chestinjuries and over 15% die over a next 30 days due to sepsis and vital organs failures. Thetime between injury and initial stabilization is the most critical period for the patientservival.Among trauma patient treated through conventional emergency services thepreventable death ranges up to 17%.The pre hospital trauma care plays great role in this,so we must emphasis on this area. Thus the time between injury and initial stabilisation which ranges between 30 to 60minutes is most critical period for patients survival. Stabilisation of general condition ofaccident victims coupled with early treatment can shorten the period of recovery. Delayon this account may result in death and permanent disability. The lessons learned insuccessive military conflicts have advanced our knowledge of care of the injured patient.Wars established the importance of minimising time from injury to definitive care. Theextension of this concept to the management of civilian trauma led to the evolution oftodays trauma systems.A trauma centre equipped with necessary modern gadgets, appliances and trainedmanpower can increase the patients survival and full recovery.Planning parameters for trauma centre :-1. Location: It should be located on ground floor and should have direct access from mainroad. A separate approach, other than the OPD with a spacious parking area for cars andtwo-wheelers is required. It should be located adjacent to the OPD to share the resourcessuch as diagnostics and also pool resources in case of a disaster.
Page 4 of 17It should be well lighted and boldly signposted both for day and night, direction signsshould be put on the main traffic routes passing through the station (If happens to be theonly trauma service in the station). Drive through and covered ambulance post should becapable of accommodating at least two ambulances.Helipad is required for major trauma centres and in rural, hilly, or unapproachable areas.Good and well maintained lawn with fixed benches and seasonal flowers serves as anadditional waiting area for relatives.2. Inter-relationship: A trauma centre should have close inter-relationship with operationtheatre, radiology, blood bank, laboratory, ICU, obstetrics, records, OPD and mortuary.Some authorities recommend close relationship with CCU as well. Many sub departmentsare required in trauma centre itself i.e. OT, diagnostics etc.3. Work & traffic flow: Efficiency of any busy and high intensity department like traumacentre can be greatly increased by smooth and orderly flow of traffic for(a) Patient(b) Staff(c) SuppliesInternal traffic flow should aim at maximising efficiency at all times. All modalities ofcommunication be employed to save time such as telephone, intercom etc.4. Entrance: Entrance should be separate from main hospitals entrance and separate forambulant and stretcher bound patients which includes a ramp. Doors of entrance shouldbe 2.4 metre wide, 2-way with glass panel at eye height and spring to keep them in openposition and they should open into the reception area. Automatic sliding doors also canbe used to prevent accidents in case of swinging doors. The entrance to registrationshould be at a close distance.
Page 5 of 175. Reception area: Entrance should open into a large open space with reception desk infront. Trolley, stretcher, and wheelchair parking area as well as a facility for cleaningstained trolleys are a must. Waiting room for patients and relatives, police desk room,room for drivers, space for medico-social worker, cafeteria, toilets, registration andrecords, security, cash counter, and telephone booth should open into reception.Other areas recommended are puja room, grief room, flower, chemist, and bookshop.Size of reception area depends on patient load, (0.75 sqm per patient for 1/3rd ofattending population in waiting area). BIS recommends 1.75 sqm per hospital bed forreception area.6. Waiting area: Waiting area is required for ambulant patients and accompanying familymembers. It is also for preventing people from entering clinical areas and can be used astriage area in case of disaster. It should be visible from reception desk. Provisions forreading material and wall posters regarding health as well as for public relation activityand facilities such as drinking water, ladies and gents toilets, television and channelmusic are a must in these areas.7. Examination and treatment area: Main area of trauma department. Going as per patientflow, the various rooms/ areas in this area are:(a) Triage area.Separate area or lobby may be used.(b) Nurses and surgeons station.It should be near entrance and registration area, with multiple communication modes,may be glass enclosed above counter level, with a private toilet. It should have work areawith lockers, refrigerators, counter sink, a small flash steriliser, IV fluids and medicinestorage.Other features are dispensing/storage cabinets, ample counter and drawer space, CCmonitoring, TV for surveillance of holding and treatment areas, bulletin boards, racks for
Page 6 of 17references and manuals, and storage area for supplies. It should have easy approach toclean and dirty utility area.(c) Examination and main treatment area.The importance of this area is Urgency in diagnosis and treatment and not any socialconsideration. It should be large, unobstructed, well-illuminated space for moving heavyequipment, stretchers, and team of health care providers. 11.5 X 11.5 metre for an opentrauma treatment room is recommended for access to patient from all sides.Treatment spaces/cubicles can be partitioned by curtains or semi-permanent booths.Where cubicles are planned they should be 3.3 X 4.5 metre in size. Doors should be atleast 1.6 metre wide.8. Resuscitation room: Thirty sq metre room required for stabilisation of injured oracutely ill patients who need care of Airway, Breathing and Bleeding, and Circulation(ABC). It is an equipment intensive area, requiring both diagnostic and therapeuticequipment such as patients trolley, piped oxygen and suction, adjustable lamps,cupboards, washbasin, worktops, as well as equipment for minor surgeries.All shelves and drawers must be clearly labelled. It should be connected to emergencyelectrical supply and from here patient will be moved either to intensive care area,operation theatre, recovery room, treatment room, or transported to a nursing unit.9. Operation room: It is required for ease in urgent surgery. There is no requirement oftransferring contaminated cases to main OT complex, and schedule of normal OT is notdisturbed by emergency cases.It is preferable to have one room for clean operations and one for septic/contaminatedcases. The latter can also be used for plaster room, both of these must provide enoughspace for staff, instrument trolley, mobile X-ray apparatus, and storage.10. Other areas required in trauma centre
Page 7 of 17(a) Plaster room: It should have provision for orthopaedic and cast work. It shouldinclude storage for splints and orthopaedics supplies, traction hooks, X-ray filmilluminators and examination lights, plaster trap is a must in the sink.(b) Surgical ICU minimum of eight beds for a centre handling 1200 cases per annum withattendant facilities, well staffed and equipped trauma ward as a step down facility.(c) Radiology: Seventy five per cent of trauma patients will require radiographicinvestigations. This dept may become a bottleneck in smooth flow if not managedproperly. Size and facility will depend on relation and distance from main radiologydepartment unless latter is just adjacent, otherwise a satellite X-ray unit is definitelyrequired.A large X-ray room may be divided by partition into two or three bays, each large enoughto carry out an examination of patient on stretcher, besides mandatory mobile unit. It isrecommended to have a static 300/500 mA unit dedicated to a large trauma department.CT scan unit for a large trauma centre and dedicated USG facility.(d) Laboratory: Type and size of laboratory will depend on relation with main hospitallaboratory. An emergency facility capable of performing routine blood and urineanalysis, bacterial smears and stains definitely is required. Advanced tests such as BGA,and biochemistry may be done in main laboratory.(e) ECG, blood bank: Closely related to or easy access to a blood bank recommended.(f) Duty room for doctors and nurses: A nine sqm room each with bed, chair, desk,bookshelf, TV, telephone, lockers, toilet and shower required.(e) Storage area: Area/alcove for mobile equipment such as mobile X-ray, crash cart,ventilators, and area for storing mobile furniture, clean instruments and linen, drugs, IVfluids, and dirty utility.(g) Janitors closet: With a designated space for waste disposal containers.
Page 8 of 17(h) Administrative areas: Offices for director and matron are required. Conference hall isrequired in a teaching institute, preferably with a reference library. Pantry of seven sqmfor providing hot and cold fluid/beverages round the clock for staff is necessary. Disasterarea 90 sqm with lighted open space, close to the entrance, with little fixed furniture andadequate storage spaces.(j) Communication room: Two way radio communication with ambulances,intercommunication between hospitals, intramural communication in the form of check-in board, PA system, telephone (including hotline), intercom, computer network anddumb waiters for supplies are now a days required in such a modern centre.11. Hospital organisation: Level I centre must have the following staff: -(a) A dedicated trauma medical director who could preferably be a surgeon(b) Trauma team:(i) General surgeon(ii) Emergency physician(iii) Surgical and emergency residents(iv) Nurses(v) Laboratory technician(vi) Radiology technician(vii) Anesthesiologist(viii) Security officers(ix) Social workers
Page 9 of 1712. Training of staff: Training of staff is of utmost importance to run an efficient traumacentre. Training is a continuous process as staff keeps on changing in a large hospital.They should not only be highly proficient in own trade but should also be trained in goodhuman relationship as well.The acute distress, anxiety and urgency on part of patient and relatives should be matchedby calm, alert and reassuring attitude of staff. Human relations and human attitudes areconsistently put to a very severe test and success depends largely on reputation ofhospital and confidence of community in its service.13. Ambulance services: An efficient ambulance service is a must for the success oftrauma system. The ambulance has been defined by the committee on ambulance designcriteria, US, as a vehicle for emergency care which provides a driver compartment and apatient compartment which can accommodate two emergency medical technicians andtwo lying patients so positioned that at least one patient can be given intensive lifesupport during transit.Two way radio communication for safeguarding personnel and patients under hazardouscondition and light rescue procedures. It is designed and constructed to afford maximumsafety and comfort. It avoids aggravation of the patients condition, exposure tocomplication and threat to survival.14. Essential requirements for a well organised trauma centre:(a) Trauma centre should be readily accessible to afford quick transfer of patient fromambulance to bed or operating table.(b) Efficient , promptly responding, well equipped ambulance service with competentpersonnel in charge.(c) Well equipped, trauma operating room with supplies always ready for use.(d) Recovery room where patient can be sent after emergency treatment.
Page 10 of 17(e) Efficient hospital personnel always on duty or on call which should include at least acompetent surgeon, nurse, and an attendant or orderly.(f) Supervision of treatment of fractures by a well qualified orthopaedic surgeon, andsupervision of the care of other injuries by those who are competent in their respectivefields.(g) Adequate diagnostic and therapeutic facilities under competent medical supervision.(h) Complete medical record of all patients treated which includes particularly immediaterecord of injury and a detailed description of physical findings, treatment and results.
Page 11 of 17Sirsa district has an area of 4,276 sq km and its population is 9,03,000. The districtheadquarter is situated in Sirsa town. It is 255 km from Delhi and 280 km fromChandigarh. Other smaller towns are Dabwali, Ellenabad, Rori and Rania. The districtlies between 29 14 and 30 0 north latitude and 74 29 and 75 18 east longitudes, formingthe extreme west corner of Haryana. It is bounded by the districts of Faridkot andBhatinda of Punjab in the north and north east, district Ganganagar and hanumangarh ofRajasthan in the west and south and Hissar and Fatehbad district in the east.Sirsa districtis divided into 3 sub-divisions and 4 tehsils. There are a total of 323 villages in thedistrict out of which 313 are connected with paved roads. About 79% of the populationlives in the rural areas. Sirsa gets an annual rainfall of about 26 cm. The area under
Page 12 of 17cultivation is 3,88,000 hectares out of which 3,06,000 is irrigated. The district excels inthe production of cotton and citrus fruit. Purpose with which Trauma centre Sirsa was opened?Haryana State is situated in the North West part of India adjoining Delhi, Rajasthan,Himachal Pradesh, U.P. & Punjab. Four National Highways i.e. National Highway No. 1(Ambala-Delhi G.T. Road), No. 2 (Delhi-Jaipur Road), No. 10 (Defence Road passingthrough Sirsa) and Delhi-Mathura Road pass through the State. Also the State Highwaybetween Chandigarh and Delhi crosses different districts of the State. National HighwayNo.10(Defence Road) is passed through Sirsa.This road joins the main border armystations like Hissar,Hanumangarh and Shri ganganagar with each other.Air-force stationof Sirsa is also situated on it.Inspite of importence in defence line,this district iscontributed in providing the health services to many adjoining areas of Panjab,Rajasthanand Haryana.All these areas depends on Sirsa for critical care,but due to lack ofsuperspeciality care the patient from sirsa hospital are referred to PGI Rohtak for furthertreatment. The time which is taken by the distance (App.5hours) cause many morbidityand mortality of injured person. About 50% of the victims die in the first 15 minutes dueto brain injuries. A further 35% die within next 1-2 hours due to head and chest injuriesand over 15% die over a next 30 days due to sepsis and vital organs failures. Thus thetime between injury and initial stabilisation which ranges between 30 to 60 minutes ismost critical period for patients survival. Stabilisation of general condition of accidentvictims coupled with early treatment can shorten the period of recovery. Delay on thisaccount may result in death and permanent disability.BY taking the account of thissituation the State Govt. has sent a proposal amounting to Rs.5.50 crores to the Govt.of India for setting up a Trauma centre at Sirsa vide letter No. 25/9-3PM-2000/3326dated 14.6.2000.Facilities proposed to be provided at Trauma Centres:- - Fully equipped Emergency wards to provide appropriate medical and surgical care to the accident victims.
Page 13 of 17 - Fully equipped operation theatres. - Intensive care Units for the seriously ill. - Neurology units for dealing with head and spine injuries - CT Scan, Ultra-sound and round the clock X-ray facilities - Laboratory services - Fully equipped orthopaedic units. - Waiting Halls for attendants of the patients - Canteens for the patients and their attendantsMACHINERY AND EQUIPMENTSr. No. Item Quantity Approx. cost1. Spiral CT 1 Rs. 2 crores2. 800 MA X-ray Machine 1 Rs. 12 lacs3. Portable X-ray Machine 1 Rs. 8 lacs4. Image Intensifier (one each for OT & 2 Rs. 30 lacs Casuality)5. Electronic Tourniquet Kit 3 Rs. 1 lac6. Battery operated Drill Machine with all 2 Rs. 7 lacs attachments for Jacobs Chunk reamers7. DHS (Dynamic with Hip Screw) 1 Rs. 4 lacs8. DCS ( Dynamic Condylor Screw) 1 Rs. 4 lacs9. Inter locking nail for flunners, libia, humans 1 Rs. 9 lacs10. Basic sets for Plating (3.5m, 4.5m) 2 Rs. 6 lacs11. Instrument set for Kuntsilmer Nailing 1 Rs. 2000012. Instrument set for partial hip Replacement 1 Rs. 2000013. Bone Nibblers, Amputation saw Curttes, 1 each Rs. 20000 Plaster Saw (Electric), Bone Cutter14. Cautery Machine 3 Rs.4000015. Orthopaedic table for OT/Casuality 2 Rs. 6000016. OT table with radiolucent top in each OT room 1 Rs. 8000017. Bulken frames for beds (one for each bed) Rs. 6000018. OT lights- ceiling/ Satellite portable OT light 2 Rs. 40000 in each OT19. Horizontal Autoclave 2 Rs.2.60 lacs20. Small Horizontal Autoclave (for casuality) 2 Rs. 6000021. Centrifugal Machine 1 Rs.4000022. Microscope Binocular 2 Rs.25000
Page 14 of 1723. Semi Autoanalyzer 1 Rs. 2.00 lacs24. Misc. item for one year Rs.7500025. Central Pipeline for Oxygen Rs.20 lacs26. Boyles Apparatus fully equipped with all Rs. 2 lacs accessories atleast one per OT27. Suction Machines in OT Rs. 1 lac28. Cardiac Monitor/Pulse Oximeter in each OT Rs. 2 lacs29. Extension board & sufficient power points for Rs. 2 lacs electricity in each wall of OT30. Ventilators for OT/ICU for prolonged IPPV Rs. 7 lacs (Intermittent Positive Procure Ventilation)31. Neurological Equipment Rs.1 crore32. Hospital Furniture Rs. 40 lacs33. General Equipment Rs. 10 lacsTotal 4.75 crores per Trauma Centre OVERVIEW OF TRAUMA CENTRE, SIRSA
Page 15 of 17 Trauma Centre Starts on : 12.04.08 Previously chosen area: 1200 sqm Current area: 1264.20 sqm Cost: 154.47lakh 1.Machinery Equipment & Instruments for Trauma Centre, District Sirsa already suppliedSr. No. General articles Quantity1 OT Table 4
Page 16 of 172 Ceiling Lights 23 Portable OT Lights 14 Suction Machine 15 ICU Beds with Mattress 56 Revolving Stool 107 Microscope 18 Calorimeter 19 X- ray machine(without accessories) 500mA 1 2. STAFF POSITION OF TRAUMA CENTER, SIRSASr. Name of the post Sanctioned Filled up Vacant Salary RemarksNo.1 Medical officer (neuro surgeon) 1 - 1 -2 Medical Officer (neurology) 1 - 1 -3 Medical officer (ortho) 2 1 1 -4 Medical officer (gen. surgery) 2 - 2 -5 Medical officer (anesthesia) 2 1 1 -6 Medical officer (radiology) 2 - 2 -7 Medical officer 4 - 4 - (gen. duty)8 Pharmacist 4 4 - 16299 - +12662 +12662 +12662 =542859 Radiographer 4 4 - 12570 1 absent +11160 from duty +11703 =3543310 Nursing sisters 1 1 - 19071 -11 Staff nurse 7 7 - 12665*7 - =8865512 OT Assistant 3 3 - -13 Lab technician 4 - 414 Store keeper 1 - 1 -15 Office clerk/ accountant 3 - 3 -16 Sweeper and ward boy On contract
Page 17 of 17 3. Services provided in the trauma center (12.04.08-23.02.09)Total Treated by Treated by Treated Referred Cause of Deathsnumber of Dr. Gaurav Dr. Chauhan (cured) referralpatients (ortho (orthosurgeon) surgeon)249 233 16 242 7 Critical 0 care Dr.Gourve Bishnoi is on call ortho surgeon from General Hospital Sirsa 4.Annual report of trauma centre : No 5.Self assessment report of trauma centre authority: No 6.Fire safety measures :No