Trauma care systems in India and China
A grim past and an evolving future
Neither India nor China has a formalized trauma system in place. There are many similarities between the 2 countries in terms of size, rapid economic growth, increasing number of motor vehicles, and high rates of road traffic accident (RTA) fatalities. This paper describes the current development of elements of the trauma system in China and the strategies and efforts made to improve the trauma system in India. In China, though not organized and formalized, different phases of the trauma system are present at varying levels of maturity. In India, efforts are made to implement a trauma system by mainly focusing on preventive measures and the creation of trauma designated facilities. Although progress has been made, the concept of “adequate trauma care for all” continues to remain an aspiration in many Asian countries, including India and China. Continued and concerted effort across many levels will be required to achieve this goal.
To date, trauma care systems in India and China are not yet well developed. Both India and China lead the world in the number of road- and traffic-related accidents and fatalities, are countries that are industrializing and urbanizing rapidly, and are nations with an ever increasing number of motor vehicles. The gap between the present level of available, efficient, and expert trauma care and the desired level of care remains large. In India and China, countries with over 1 billion inhabitants each, trauma care services are mainly available in urban regions, resulting in an increased incidence of deaths from traffic accidents in rural areas and on highways. The lack of an organized trauma care system has contributed to a wide disparity in trauma care delivery throughout these countries.
Approximately 6% of the global RTAs annually occur in India, even though it only has 1% of the world's vehicles. The RTA rate of 35 per 1000 vehicles and the RTA fatality rate of 25.3 per 10,000 vehicles is the highest in the world.The RTA mortality rate in China amounts to more than 6 deaths per 10,000 vehicles, which is significantly lower than India, but still higher than other countri In 2011, in India, a RTA-related death occurred every 4 minutes.The burden of RTAs continues to increase at an annual rate of 3%, leading to disabilities and fatalities and causing social, emotional, and economical losses. In 1997, 10.1% of all deaths in India were due to the result of accidents and injuries. During 1998, nearly 80,000 lives were lost and 330,000 people were injured. In 2011, these numbers increased to 142,485 RTA fatalities and 497,686 RTA injuries. In China more than 2 million persons are injured per year and more than 600,000 fatalities are reported due to trauma. The proportion of fatal accidents in total road accidents in India has consistently increased from 18.1% in 2002 to 24.4% in 2011. Similar to other parts of the world, RTAs mainly involve younger individuals, which significantly impacts work productivity. In 2016, almost 140,000 RTA-related fatalities were reported in India of which 68.6% involved those between the ages of 18 and 45 years. In China, 10% of all deaths were associated with RTAs, with those aged ≤44 years accounting for two-thirds of the mortalities. Because of the rapid motorization in the past decades, RTAs in rural areas have increased significantly in recent years adding to the surgical and economic burden.
Neither India nor China has a formalized trauma system in place. There are many similarities between the 2 countries in terms of size, rapid economic growth, increasing number of motor vehicles, and high rates of RTA fatalities. This paper describes the current development of elements of the trauma system in China and the strategies and efforts made to improve the trauma system in India.
2 Trauma care in China
At present, China neither has a formalized and coordinated trauma system, nor has a mature national trauma registry. Providers are, however, able to utilize data from the National Injury Surveillance System. Established in 2006 in 126 hospitals, the system uses the World Health Organization's Injury Surveillance Guidelines and allows for a better understanding of the nation's trauma related injuries.
2.1 Current state of the trauma system: prehospital care
Emergency medical services in China is still underdeveloped and not formalized. Different entities are still very isolated and often operate independently throughout cities and counties. There is a lack of communication and information sharing between regions resulting in ineffective interhospital transfer. Since there is no proper communication system between prehospital care and the receiving hospital, it is not uncommon that a trauma patient is sent to a hospital with inadequate resources. As for now there is not a mandatory setup for trauma care required by legislation. China's current Emergency Medical Services system mainly relies on ambulances. Due to high costs, air transport by means of helicopters is only available in a few large cities. RTAs in China get reported to the traffic policeman and the Emergency Medical System at the same time. Deployed ambulance vehicles function under the direction of the traffic police or individual hospitals. Currently, the ambulance crew consists of a doctor, a nurse, and a driver. To ascertain adequate coverage in urban regions, Emergency Medical System stations are located within a 5 km radius of each other. Each station is equipped with 4 reception staff members. The average response time from call to the accident scene is approximately 10 minutes, and the response time in rural areas is doubled.
2.2 Current state of the trauma system: resources and facilities
Professor Jiang Baoguo of the People's Hospital of Peking University led the establishment of the China Trauma Treatment Alliance, and 100 hospitals participated in the treatment protocol establishment. At present, a number of hospitals have gradually established trauma centers to effectively manage patients with severe trauma. These trauma centers encompass health care professionals from orthopaedics, neurosurgery, and other relevant departments.
First class hospitals (Grade A) in cities are mostly overloaded, and the lack of available operating rooms impedes the efficiency of work. Since there are no dedicated orthopaedic trauma operating rooms, trauma procedures are prioritized after emergency procedures from other departments such as obstetrics, general surgery, and neurosurgery, adding to the delay in care.
Besides operating room availability, access to specialized surgical instruments and implants is limited to the wealthier and larger cities such as Beijing, Shanghai, and Guangzhou. Most of the implants are imported. Various plates and intramedullary nails are widely used. The use of these expensive imported products not only further helped develop the field of Chinese orthopaedic trauma but also has increased the financial burden to patients and public health care insurance. Domestic implants occupy the dominant position in the second-tier cities of China, accounting for almost 80% of implants used. Unfortunately, the quality of the domestic made instruments is still not satisfactory. To improve this, some companies work closely with orthopaedic surgeons to develop better implants and medical devices for Chinese patients. These efforts are expected to greatly reduce the medical expenses and thus the overall financial burden.
2.3 Current state of the trauma system: postresuscitation and rehabilitation
Postoperative rehabilitation of trauma patients is an underdeveloped phase of the trauma system in China. Many hospitals still do not have rehabilitation departments at their disposal, and historically most surgeons that take care of the initial trauma seem to focus less on postoperative rehabilitation strategies. Fortunately, in recent years, attention to improve rehabilitation strategies has gradually increased. The Rehabilitation Department of the Third Hospital of Peking University, which has been established for 26 years, has made great contributions to rehabilitation medicine in China. At present, the rehabilitation and orthopaedic trauma departments have been able to cooperate closely. To further improve care during this phase of the trauma system, rehabilitation departments of central cities should provide training for rehabilitation departments in primary hospitals and hospitals in more rural areas.
2.4 Current state of the trauma system: access to care
The Chinese public health care insurance system is gradually expanding coverage, and the government is energetically promoting the national health care insurance system. In the past 20 years, health care insurance has expanded from the urban region into the rural areas of the country. Currently, most of the population is covered by health care insurance. The elderly and pediatric populations in urban regions can be covered by medical insurance for an annual fee equivalent to 20 United States Dollars (USD). It has greatly relieved the economic burden at the level of the individual and has become the cornerstone of improving social stability. However, China is still a developing country, and its revenue is not enough to cover all health care expenditures. Even with the health care insurance, urban residents still have to co-pay 20% to 30% of the expenses and a substantial portion of the implants and medical devices used. If the traumatic injury is caused by another person, such as through a motor vehicle accident, the responsible person must pay for the cost of treatment. If the responsible person does not have the ability to pay, the injured person will bear his or her own financial burden.
2.5 Current state of the trauma system: education
The Chinese Association of Orthopaedics (CAOS) has pushed the education system to put more emphasis on orthopaedics during the curriculum. As a result, instead of only 6 months, the orthopaedic residents will participate in training focused on trauma for 16 months. The specialist education is still very limited in China. Educational opportunities such as the Arbeitsgemeinschaft fur osteosynthesfragen/Association for the study of Internal Fixation (AO) Basic, AO Advanced, and AO Masters Courses in China are most welcomed by the orthopaedic surgeons. To improve resident education, the CAOS is actively recording and evaluating the results of the orthopaedic curriculum. To further strengthen the knowledge and skill set of the Chinese orthopaedic surgeons, a select few are sponsored by the CAOS and Chinese National Foundation to participate in fellowship training abroad.
3 Trauma care in India
For years, the development of trauma systems was underappreciated by the Indian government. Now the government recognizes the challenges of developing a mature trauma care system that includes all phases from prevention strategies through road safety, education, prehospital care, and physical resources and facilities.
3.1 Current state of the trauma system: physical resources and facilities
Similar to China, to date there is no formalized trauma system in place, but efforts to implement a system are being made. The public health care system in India is divided into primary health, secondary health (level 2), and tertiary health (level 1) care centers.
The primary health care units serve a population of approximately 20,000 to 30,000 patients. It is the most basic unit, comprised of a medical officer and paramedical staff. This unit forms the basis for the health care for communicable diseases, maternal and child health, and health education about prevention of the communicable diseases and population control. These centers are incapable of handling trauma, as they have inadequate human resources, training, and infrastructure. Trauma patients are mostly referred to the district centers.
The secondary health care centers (level 2 trauma care units) are small district hospitals wherein a general surgeon, orthopaedic surgeon, internal medicine physician, pathologist, and radiologist, are available 24 hours, 7 days per week. These setups have a well-equipped operation theater where traumatic injuries can be operated on routinely. They lack the availability of some subspecialists, such as vascular surgeons or dialysis units. Complicated cases requiring these subspecialists are referred to the level 1 trauma care centers.
Tertiary health care centers (level 1 trauma care units) are the medical college/academic hospitals and the bigger district hospitals where all the requisites for a level 1 trauma care center are available. They are able to handle all of the polytrauma cases. Another setting is the advanced medical research institutes with trauma care facilities. These are few in number and are mostly concentrated in and around the metropolitan areas and larger cities, but are fully equipped and able to handle any complex trauma cases.
3.2 Implementing the trauma system: preventive measures
One of the pillars of the implementation of a trauma system in India is improving road safety. Road safety and vehicle safety action plans were formulated with the annual goal of reducing RTAs. National road safety measures have been approved by the Government of India, and the ministry has formulated a multipronged strategy based on education, engineering, enforcement, and emergency care.
In view of the national interests and a nonadversarial stance of the Indian government, the Supreme Court passed an order to institute a committee on road safety under the Chairmanship of Justice K. S. Radhakrishnan, a former judge. The court acknowledged that the mortality from RTAs was 139,671 in 2014, which subsequently jumped to 146,133 in 2015. In 2017, the Supreme Court recognized that the Indian government had acknowledged the problems secondary to RTAs and prepared a Bill amending the Motor Vehicles Act of 1988.
Measures improving engineering and enforcement have also subsequently been developed. The overarching plan consists of multiple initiatives. A committee headed by the Collector of the District will determine targets for reductions in accidents and fatalities, dependent upon data for specific districts. District road safety committees will include the superintendent of police, health officers, public works department engineers, representatives of the National Highway Authorities of India (NHAI), and regional transit officer. Further, the Ministry of Road Transport and Highways will set up protocols for the identification and rectification of “black spots,” which are locations of high RTAs. State governments will be directed to adopt Traffic Calming Measures at these accident prone areas, junctions of lower hierarchy roads, and other vulnerable spots like schools and hospitals. All state governments will take steps to acquire and use cameras and other surveillance equipment according to the norms suggested by the Ministry of Home Affairs to check and detect traffic violators, provide special patrol forces along the national and state highways, and expressways. The state governments will also ensure that road safety education and counselling is incorporated into the State Board curriculum and will install speed governors in vehicles and attribute a unique identification number for monitoring purposes. On a national level, the NHAI must have a permanent Road Safety Cell consisting of suitable engineers and qualified personnel.
Other measures addressing road infrastructure, automobile construction, and driver behavior are also being addressed by the new initiatives. Road safety audits will be performed by road safety experts, new roads will be built and old ones better maintained, and encroachments along the roads will be removed. There will be recommendations for the installation of improved breaking systems, airbags, and automatic headlights in all models of cars, and all vehicles must pass valid crash test standards conducted by independent bodies. Driver license renewal will be subject to more stringent criteria and will be suspended for a period of at least 1 year for speeding, red-light jumping, cellular phone use while driving, overloading, and using goods carriages to transport passengers. Those found to be driving under the influence of alcohol will be prosecuted. Policies will be developed for the removal of all objects that obstruct driving or distract drivers. These preventive measures have been proven effective in reducing fatalities from RTAs, and their implementation will be imperative to improve road traffic safety.
3.3 Implementing the trauma system: education
Educational initiatives are aimed toward individuals’ awareness of and training in basic life support (BLS). Orthopaedic societies, in general, and orthopaedic surgeons, in particular, can help reduce the burden of RTAs by educating the road users by educating the public about the consequences of RTAs. Methods could include various audio-visual lectures stressing the importance of and need to follow traffic rules. One such study was conducted by the authors and the Vidarbha orthopaedic society wherein the attitudes of 1700 college students between the ages of 18 and 25 years were studied, before and immediately after an audio-visual lecture in which the hazards of RTAs were explained. It was observed that more than 96% of students showed a positive attitudinal change toward the road traffic rules and safety. The same set of students was once again tested for their attitude toward road safety 2 months after the initial presentation. It was observed that these students regressed toward their initial attitudes regarding adherence to road safety rules. It was concluded that students repeatedly should be made aware of the hazards of RTAs so as to maintain improved attitudes toward road safety rules.
Similar to the need to educate the population about road safety rules, there is also a widely shared opinion that BLS and its importance should be disseminated. Most of the population and, thus, road users lack formal training about how to impart first aid to RTA victims. In order to improve first aid to RTA victims, it is now highly recommended to train the population on BLS skills.
3.4 Implementing the trauma system: prehospital care
The Ministry of Road Transport has established a fully equipped ambulance unit bearing a toll-free number commonly available throughout the country. The goal of this effort is to establish emergency medical care for every district. At least 1 trauma care center with all modern medical facilities and ambulances manned by trained para-medical staff and equipped with first-aid capabilities should be made available. In daily practice, this means that the trauma care network is designed in such a manner that no trauma victim has to be transported for more than 50 km to a designated hospital with trauma care facilities. For this purpose, an equipped BLS ambulance will be deployed by the NHAI (Ministry of Road Transport and Highways, MRTH) at distances of 50 km on designated National Highways.
3.5 Implementing the trauma system: resources and facilities
The goal for national trauma care is to implement a tiered trauma system consisting of 4 levels:
Level IV trauma care would be provided by appropriately equipped and manned mobile hospital and ambulances provided by MoRTH, NHAI, MRTH, state governments, and other relevant institutions.
Level III trauma care facilities provide initial evaluation and stabilization (surgically if appropriate) to the trauma patient. Comprehensive medical and surgical inpatient services would be made available to those patients who can be maintained in a stable or improving condition without specialized care. Emergency doctors and nurses, other physicians, surgeons (including orthopaedic surgeons), and anesthetists would be available 24 hours, 7 days a week to assess, resuscitate, stabilize, and initiate transfer as necessary to a higher level trauma care service. Such hospitals will have limited intensive care facilities, diagnostic capabilities, blood banks, and other supportive services. District hospitals with bed capacities of 100 to 200 beds would be selected for level III care.
Level II trauma care facilities would provide definitive care for severe trauma patients. Emergency physicians, surgeons (including orthopaedic surgeons), and anaesthetists would be in-house and available to the trauma patients immediately on arrival. These facilities would also have on-call neurosurgeons and paediatricians. If neurosurgeons would not be available, general surgeons trained in neurosurgery for a period of 6 months in eminent institutions would be made available 24/7. The centers should be equipped with emergency departments, intensive care units, blood banks, rehabilitation services, broad range of comprehensive diagnostic capabilities, and supportive services. The existing academic hospitals or hospitals with capacities of 300 to 500 beds should be identified as level II trauma centers.
Level I trauma care facilities would provide the highest level of definitive and comprehensive care for patients with complex injuries. Emergency physicians, nurses, and surgeons, including all of the major subspecialty services, would be in-house and immediately available to the trauma patient 24/7. These facilities should be situated at distances of <750 to 800 km apart, and necessarily along highway corridors. These centers should be tertiary care facilities where patients requiring highly specialized medical care are referred. Due to high levels of skill, specialists, and infrastructure required, level I trauma centers should only be located in academic hospitals.
The new trauma care facilities would be located on national and state highways that connect all the major and populated areas including 2 major cities, capital cities, ports to major cities, and industrial townships to capital cities. The criteria for the northeastern and other high altitude states should be relaxed in respect to hospital beds and distances, keeping in mind their location, local proclivity for accidents, and difficulty accessing the terrain.
The MRTH, Indian government, and various state governments maintain a database of “accident blackspots” (locations/stretches where RTAs have historically been concentrated). These blackspots are often due to improper road engineering, unsafe driving behavior, and the absence of pedestrian crossings and contribute to almost two-thirds of RTA deaths. Hence, it is extremely important to co-locate the trauma care facilities within a reasonable distance from the blackspot so as to ensure definitive care to the injured with the golden hour. Consequently, when identifying health care facilities to upgrade under this scheme, priority should be given to existing hospitals in the state that are within a 100 km radius of identified blackspots and with high mortality rates due to RTAs despite all possible road safety interventions. Under this scheme, the State Governments would be required to nominate an appropriate official as the State Nodal Officer who would be the single point of contact with the Ministry of Health and Family Welfare (MoHFW) for all activities related to the scheme. The State Nodal Officers would be responsible for submitting self-contained proposals to the MoHFW. Following the receipt of proposals from the state governments, the MoHFW initially would evaluate them on a case-by-case basis. Shortlisted hospitals would be visited by a MoHFW team for a detailed gap analysis and feasibility study that would be the basis for a recommended decision. The designation of the identified trauma care facilities as level I, II, or III would be determined by the MoHFW based on factors that include expected loads, morbidities, and mortality profiles of the trauma cases in the catchment areas, level of other trauma care facilities around the hospitals, and status of existing services at the hospitals.
So far, the government, in its attempt to reduce the morbidity and mortality due to RTAs, has implemented upgrades to existing medical colleges, academic hospitals, and larger district hospitals to level I, II, or III trauma centers. In its “11th” 5-year plan, the Indian government has upgraded 118 district hospitals and academic hospitals to levels I, II, and III based on their workloads and the vicinities in relation to accident hot spots. The “12th” 5-year plan further helped to upgrade 54 centers to various level trauma care units. Health care providers have been improved through appropriate skill training throughout the developing trauma care system.
The think tank National Institution for Transforming India (NITI Ayog) has further developed plans for creating trauma care units along the national highways covering the Golden Quadrilateral Corridor (5846 km), North–South and East–West Corridor (7716 km) by establishing 140 trauma centers at a cost of 732.25 crores (110 million USD). The scheme has now been extended under the 12th Plan as well, with an aim to establish 85 more trauma care centers (5 level I, 25 level II, and 55 level III) in government hospitals in or around national and state highways, preferably in accident-prone areas on these highways and in states not covered earlier at an estimated cost of 534.64 crores (80 million USD). Lastly, another goal is to develop a National Injury Surveillance System and Trauma Registry.
The future appears both daunting and challenging. It is estimated that the present position of RTAs as the ninth-leading cause of death in India will move up to the third-leading cause by 2020, increasing the surgical and economic burden dramatically. With the current rate of motorization, similar trends are to be expected in China. To meet this colossal challenge, several efforts are required, some of which already have been initiated, including preventive measures, resource creation, education, legislation, access to care, optimizing prehospital care, dedicated hospital-based trauma care, rehabilitation strategies, and awareness amongst the population and policy makers. Although progress has been made, the concept of “adequate trauma care for all” continues to remain an unrealized goal in Asian countries like India and China. It will take a continued and concerted effort from all of the stakeholders to achieve such a goal.