Article 683 a 02 TraumaonHighways

8/12/2019 Article 683 a 02 TraumaonHighways

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There is Good News on the National Highways. The Government of India finally, has started working on plans

to institutionalise trauma care on highways as part of the XIth five

year plan.

With a proposed plan allocation of Rs. 732 crores over the planperiod of 2007-12, this is Government of Indias first majorinitiative to address the issue of post accident management ofinjured victims - pre-hospital and within care centres. However, thiscost does not include the cost of proposed deployment ofambulances and manpower by NHAI and MORT&H, since these are part of the ongoing

NHAI and MORT&H activities. Also not included is the cost of manpower to beemployed at the Level I, II and III Trauma Care Centres, (as explained later) which areto be charged to the NRHM (National Rural Health Mission) as is the major cost of up-gradation of 20 Level I centres being already covered under the Pradhan MantriSwastha Suraksha Yojana.

Being orchestrated jointly by the Central Ministries of Health & Family Welfare andRoad Transport & Highways, the project was first thought of during a meeting of thetwo central Ministers, convened for the specific purpose.

Over a couple of years, various committees in both the ministries and then crossfunctional committees with representations from Govt. agencies, medical care expertsand non-profits (Lifeline Foundation being part of a committee under the Ministry ofRoad Transport) deliberated on the concept.

At the end of it, a document was prepared, laying down logistics, infrastructurerequirements, standards for equipments and most importantly manpower trainingcourses, their structures and training institutes. It is till date, the most

comprehensive plan ever documented by GoI. This article tries to lay down thefeatures of the plan; subsequent issues will analyse the efficacy, utility andfeasibility of each of these features.

By its very design, the scheme is specific to hospitals located along the National Highways.

The PROJECT bases itself on two defining documents:

1. .

It states that

for trauma care of India

The Project for Trauma Care on National Highways, hereafter referred to as thePROJECT identifies the Ministry of Road Transport & Highways (MORT&H),Ministry of Health & Family Welfare (MOH&FW) and respective state governmentdepartments of Transport, Health and Police as executing agencies.

The draft Road Safety Policy

the Government will strive to achieve its target that all personsinvolved in road accidents benefit from speedy and effective trauma care and health

EMSEMS IN IINDIAenchmarking The Golden HourBenchmarking The Golden Hour

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management. The essentialfunctions of such a servicewould include the provisionof rescue operation andadministration of first aidat the site of an accident,

the transport of the victimfrom accident site to ana p p r o p r i a t e n e a r b yhospital.

The d ra ft pol icy a lsodelineates the followings tr at eg ie s t o i mp ro veemergency medical servicesalong National Highways:

Improve communicationsystems available with

p o l i c e a n d o t h e r

emergency services as am e a ns t o r e d uc eresponse time

Train police, fire andother emergency service

personnel in traumacare

D ev el op l oc al a nd regional trauma plans

2.

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The report pointed outglaring deficiencies, whichthe PROJECT attempts toaddress in the 11th five year

plan.

The MOH&FW piloted aproject in 1999 during the9th five year plan. 18h os p it al s l o ca te d o n

National Highways in 13states/UTs received a grantof Rs. 1.5 crores each forstrengthening of emergencycare facilities.

During the 10th p lan,a no th er 8 5 h os pi ta ls

An evaluation of thee xi st in g p ro je ct s o nTrauma Care piloted by

the Health Ministry, GoIunder the 9th and 10thfive year plans and theannual plans

The 10th plan had an outlayof Rs. 110 crores while the

current annual plan has aseparate budget of Rs. 100crores.

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Trauma Care on Highways

Beautiful exterior, delicious interior!


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received similar grants. A total of 103 institutes have collectively benefited from astate largesse of Rs. 139 crores over two plans.

However the evaluation carried out by Regional Directors for Health & FamilyWelfare in different states based on inspection of these 103 institutes stated that thescheme had not delivered the expected outputs in terms of trauma care due to various

reasons; primary reasons being: substantial delays in constructing the structures,inability to deploy manpower, lack of formal training in EM and hospitals selectedwere stand alone institutes without any integrated referral system.

Following this proposed review, the PROJECT would then be extended to coverNational Highways connecting capitals of adjoining states, connecting major cities otherthan state capitals, connecting ports to major cities and industrial townships to respective

state capitals.

Under the PROJECT, a trauma care network would be put in place so that there will be adesignated trauma centre at every 100 kms on the highway. This would mean that at any

point in place or time, a trauma victim will not have to be transported more than 50kilometres for care.

The proposed PROJECT would have various components; some of key ones would be:1. Designated Trauma centres2. Trained and technically skilled manpower3. Training modules and courses to train such manpower4. Civil Infrastructure5. Life saving Equipment6. Communication Systems7. Trauma Registry and Injury Surveillance

There would be four levels of Trauma Care Centres starting with Level IV and going upto Level I, the apex centres.

The Level IV centre would be a mobile hospital ambulance. These 24x7 BLSambulances would be stationed at a distance of 50 kms apart from each other. Theywould be manned by a driver and two trained paramedics. These personnel wouldidentify extent of injury and provide BLS at site and during transportation to thehospitals. These ambulances would be provided by NHAI through their maintenancecontractors, who would also have to bear the cost of these facilities as per the plan.

Additionally Advanced Life Support Ambulances would be stationed at every district

hospital provided by MORT&H. The operational costs including those for staffing wouldbe borne by the NRHM. These ambulances would transfer trauma victims to higher levelcentres if required.

In light of the feedback and the consensus that emerged during consultations withvarious stakeholders, it was proposed to design and develop a network of Trauma CareCentres that would cover, in the first phase the entire Golden Quadrilateral (GQ) andthe North-South-East-West Corridor; this was a step to move towards the desiredobjective of bringing down preventable deaths in road accidents to around 10%.

Trauma Care Centres :

Schematic diagram showing location of different levels of trauma care for a length of1400 kms of National Highways.

The Level III Trauma CareCentre under the PROJECT

p r o v i d e s s t a b i l i s a t i o n(surgically, if needed) to the

patient. Such centres wouldhave ICU facilities, blood

bank, diagnostic departmentsand other necessary supportives e rv i ce s . T h e h o sp i ta l sidentified are the districthospitals of 100 to 200 bedcapacity. Specialist care would

be made available round theclock as per the norms created

by the DGHS.

Existing teaching hospitalswith 300 to 500 beds at adistance of 200 to 250 kms

apart, would provide definitivecare for severely injuredvictims. These would be theLevel II care centres. Internists,Surgeons, Orthopaedicians andA n ae s th e ti s ts w o ul d b estationed, round the clock, atthese centres. They would be

backed by the services of oncall neurosurgeons, fullye q u i p p e d E D s , I C U s ,diagnostic, rehabilitative andsupportive services besides

blood banking facilities.

Level I Trauma Care Centreswould provide for all majorsuper specialties associatedwith trauma; these would besituated at a distance of 750 to800 kms apart and need not bealong the Highways, sincethese are centres where victimsrequiring highly specialisedmedical care would be shifted.

These are centres, which are

being upgraded under thePradhan Mant r i Swas thaSuraksha Yojana; these centresalso include those yet to be setup AIIMS like centres' in sixstates.

T he P RO JE CT h as t hi sambitious plan of providing forone way telephone every 5kms (on similar lines asoperational between Delhi andJaipur) on highways to access adedicated four digit accidenthelpline number. These will

Communication Systems :


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Level-I Level-II Level-III Level-IV


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connect directly to the nearest mobile unit or the control centre,which will be managed 24 x 7 at the trauma centres by the staffon duty. These staff in turn will guide the pre-hospital careactivities in the ambulances and co-ordinate with the higher levelcare centres if necessary.

The PROJECT would need a lot of professionals trained inemergency and trauma care. There is an estimate (though yet to

be substantiated) that India would require 40000 trainedparamedics by the turn of the decade.

The PROJET itself would require, by conservative estimates, more than 5000 trainedambulance personnel in its first phase of GQ and Corridors coverage.

The PROJECT has included training as a very significant component. Two courses havebeen devised by the Ministry of Health. The PROJECT draws from the Thailandexperience where Trauma Care Centres are nurse centric. A training course for nurses inmedical care training and one for technicians in emergency medical care have been

prepared, the syllabus of the former is being drawn up by the Indian Nursing Council.

The PROJECT envisages an incentive scheme for qualified nurses to undertake thetraining. The Central Govt. would, for the plan period, fund the allowance for threenurses per trauma centre, which would ensure that for each shift at a centre, there isadequately trained staff.

As a first step, nurses from the 103 centres, which have been aided during the 9th and10th plans (as mentioned earlier) would be invited to join the course, proposed to beinitiated at the Rajkumari Amrit Kaur College of Nursing.

Similarly, the course of Emergency Medical Technicians would be run at three institutes,as proposed; these institutes would be provided an aid of Rs. 20 lacs as seed money for

the PROJECT.

Besides these, the PROJECT proposes to initiate, for the first time in the country,transfer protocols in Government set-ups on auniform standardised pattern. Proposals forestablishing a much needed Trauma Registry, InjurySurveillance and Legal Service Cell would be path

breaking initiatives for trauma care in the country, ifimplemented.

It is also proposed to strengthen 140 hospitals onhighways along GQ and the Corridors. Assistancefor each Level III centre is targeted to be Rs. 4.8crores after duly assessing each centre as per theinfrastructure check list of DGHS.

Similarly an upper cap of Rs. 9.65 crores is proposed for the Level II centres. ThePROJECT envisages funding of Rs. 3.2 crores for the Level I centres forcommunication, legal services, training and seed money; this is because the 30 identifiedLevel I centres are already in various stages of up-gradation or implementation beingsupported by the Pradhan Mantri Swastha Suraksha Yojana.

Unlike various RTA linked schemes of different state govts., a nodal ministry has beenidentified for this PROJECT - the MOH&FW. This is a major step forward, since almostall previous attempts did not have a singular ownership and hence collapsed over time.

A technical committee in the Health Ministry, headed by a GoI Addl. Secretary levelfunctionary has been constituted to identify trauma centres requiring up-gradation underthe PROJECT. Monitoring being an important component of the PROJECT, steps are

Professional Courses for Emergency Medical Care :

EMSEMS IN IINDIA

being initiated to form acommittee for the same,comprising of representativesf r om c e nt r al m i ni s tr i esinvolved in the PROJECT andthose from various states.

It has also been suggested thatall states, wherever suchactivities are being aidedwould have to sign an MoUwith MOH&FW for

.This in itself is an extremelylaudable effort.

The policy makers expect thefollowing outcomes:

1. Bring down number ofp r e v e n t a b l e d e a t h ssignificantly

2. Crea tion o f an injurys u r ve i ll a n ce n e tw o r k contributing to safety policyformulation and medicalaudit of services

3. Formation of a ool oft r ained manpower for

Emergency Services4. Development of nation wide

network for trauma care

5. Open up public-privatepartnerships

6. S yn er gy o f o n g oi n ginit ia tives by differentagencies for providingtrauma care services

7. Capacity building in districthospitals

In terms of timelines, the

PROJECT is to be handed overto respect ive StateGovernments once the 11th

plan period ends. From thereon, a further 160 newinstitutions and other highwayswould be the target of the 12thfive year plan. B

Let us get started on this first.

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inter-aliar et a in i n g t h e r eq u i r ed manpower at the selectedcentres and also for acceptingthe liability of the manpowerbeyond the 11th plan period

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ut that is along way off!

Dr. Subroto Das

The Author is Ashoka Fellow& Managing Trustee & CEO,

Lifeline Foundation, Vadodara

A barely functional Trauma Centreon National Highway

Article 683 a 02 TraumaonHighways

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