Assignment 6.3: Advocacy Action Plan/Screen-recorded Oral Presentation
Rolly
S_Warren_Final_Intervention_Proposal1_AP2.pptxPopulation Health Intervention Proposal Zero Preventable deaths From Trauma: How Can We Stop The Bleed?
Shannon L. Warren
The University of Texas At Arlington College of Nursing and Health Innovation
In Partial Fulfillment of The requirements of
N6307 Population Health
Rebecca Garner DRPH, CPH
June 25, 2019
Hello, my name is Shannon Warren and I am a student in the DNP program at the University of Texas at Arlington College of Nursing and Health Innovation. As a final project for N6307 Population Health, I am going to present an Interventional Proposal to address Zero Preventable Deaths From Trauma and how we can stop the bleed.
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Overview
Figure 1: Boston Marathon Bombing (Ken McGagh/MetroWest Daily News/AP, 2013). Retrieved from http://4.bp.blogspot.com/-G7VjHzBRMK8
/UW32xbHJFyI/AAAAAAABC4E/3h2OCfgC3-w/s1600/boston+bombings+Ken+McGagh+MetroWest+Daily+News.png
Preventable deaths after traumatic injury and hemorrhage continue to increase despite advances in trauma systems and care. Delays in treatment have increased the mortality in those victims whose injuries were serious, but would have been survivable. Bystanders, those individuals that are a witness to the traumatic event, are wasted human resources that could be lifesaving first responders and EMS providers are without the tools needed to minimize the delay to rapid initiation of life saving volume resuscitation. Change efforts focusing on health related interventions in a community should utilize a planning model that encourages and increases participation and ownership of the intervention from members of the community. It is imperative to implement these community appropriate evidence-based interventions, for only then will we be able to positively impact and decrease the number of preventable deaths from traumatic injury and hemorrhage.
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Preventable deaths after traumatic injury and hemorrhage continue to increase despite advances in trauma systems and care
Bystanders are wasted human resources that could be lifesaving first responders
Community planning model for change
Evidence based interventions to the problem
EMS providers lack the tools to initiate rapid volume resuscitation
Increased survivability of the traumatically injured hemorrhaging patient
Introduction
Population health problem
Preventable deaths after traumatic injury and hemorrhage
Population affected
residents in a community
Intervention
Evidence-Based Pre-hospital hemorrhage control education
Figure 2: Mass Casualty (Google Images, nd) Retrieved from https://cdn.boundtree.com/assets/btm/University/Articles/
allresources/how-to-practice-the-ems.jpg
Preventable deaths after traumatic injury has been defined as “casualties whose lives could have been saved by appropriate and timely medical care, regardless of tactical, logistical, or environmental issues” (Spinella, 2017, pgs. S2). Daily reporting of these events related to acts of “terrorism, the actions of unstable people, and the dangerous impulses of friends and relatives are very real and becoming increasingly more frequent” (BleedingControl.org, nd, para.1). Preventable deaths after traumatic injury is a global health problem that can affect anyone anywhere. More than nine people die every minute from injuries or violence, that equates to approximately 5.8 million people who die each year from both unintentional and violence-related injuries worldwide (CDC, 2017). Every six minutes, someone in the United States (US) dies from trauma or trauma related injuries and another is permanently disabled (CDC, 2019). Trauma can also lead to other significant mental and physical health consequences such as depression, anxiety, pregnancy complications, and even chronic diseases such as diabetes and heart disease (D’Andrea, Sharma, Zelechoski, & Spinazzola, 2011). In the United States (US), preventable death rates after traumatic injury are between 20–27.5%, and of these, preventable deaths due to hemorrhage range between 64% and 90% (Spinella, 2017). Approximately 612,000 deaths per year in civilian settings globally can be estimated to be preventable hemorrhagic deaths after injury (Spinella, 2017). Rapid treatment is essential and necessary for those victims whose injuries are serious but survivable (Williams, 2019). Utilizing evidence -based research, the intervention proposal will target pre-hospital hemorrhage control education which can turn bystanders into lifesaving first responders, by training them to use manual compression or tourniquets to control hemorrhage and improve survivability.
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Identification of Need
The reporting of critical injuries related to trauma is a daily news occurrence. Even with so much attention, “death from injury” has been “the neglected epidemic of modern medicine” (Eastridge, et al., 2019, pg. 1423). The creation of structured trauma systems is focused on improving injury care nationwide (Alarhayem, et al., 2016). An important component of this improved injury care, was the identification of the “golden hour”, which determined that rapid initiation of care (within the first hour of injury) to those critically injured impacted victim’s chances for survival (Alarhayem, et al., 2016). Hemorrhage is the leading cause of preventable trauma deaths and occurs rapidly (median 2–3 hours after presentation) (Chang & Holcomb, 2017). In every community, there are individuals that will be witness to some traumatic event requiring rapid intervention and external hemorrhage control. In the community, those bystanders or individuals that are a witness to the traumatic event, are an underutilized resource that with the proper training can make a significant impact on the survivability of a trauma victim requiring external hemorrhage control.
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increase in mass casualty shooting events throughout the country
increases in traumatic events either locally or in nearby communities
A person who is bleeding can die within five to eight minutes1
Medical first responders may not always reach victims in time to prevent exsanguination2
In the prehospital environment, hemorrhage is the most significant preventable cause of death3
(Williams, 2019)1 (Navarro, 2016)2 (Jacobs, et al., 2015)3
Target Population
Figure 3: Officer Down/MCT Force Protection (Bing Images, nd) Retrieved from https://www.bing.com/Images/search? view= detaiv2&id=45663 9AE6BDAF5E
(Joint Committee To Create A National Policy To Enhance Survivability From Intentional Mass Casualty Shooting Events, 2013)2
(Alarhayem, et al., 2016)1
Mass casualty shooting events and mass casualty events continue to occur more frequently than ever before. Studies have shown that effective rapid intervention for victims affected by a mass casualty event increases their survivability (Ross, et al., 2018). Vulnerable populations are especially impacted. In the United States alone a significant number of the population, 38.4 million, does not have access to trauma care within one hour of driving time and certain vulnerable groups are at higher risk than others for worse access to trauma centers (Hsia & Shen, 2011). As early as the 1960’s, it was clear that injury had become a significant public health problem (Alarhayem, et al., 2016). These problems require a population health approach to assess, plan, implement, and evaluate public health programs created to address population health deficiencies in a community. The creation of structured trauma systems has focused on improving injury care for all nationwide (Alarhayem, et al., 2016).
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Trauma has no preferences in who it devastates
Traumatic events are not confined to specific locations
Preventable deaths after traumatic injury is a global health problem
Treatment for those critically injured within The “golden hour” can impact a victim’s survivability1
immediate management of hemorrhage control is needed to maximize survival2
Planning Model Precede-proceed
Figure 4: Precede-Proceed (Image). Retrieved from https://wol-prod wol-prod-cdn.literatumonline.com/cms/ attachment/9a0d1eff-62b7-404b-8692-97ce2418130a/jphd_235_f1.gif
PRECEDE
Predisposing
Reinforcing
Enabling
Constructs in
Educational/environmental
Diagnosis
Evaluation
PROCEED
Policy
Regulatory
Organizational
Constructs in
Educational and
Environmental
Development
Planning models for change are best thought of as organized frameworks for an entire health promotion effort that is aimed at fostering reduction in a given disease (Crosby & Noar, 2011). For this final project, The Precede-Proceed planning model will be utilized as it provides structure for not only “planning a targeted and focused public health program”, but also for “implementing and evaluating the public health program” (Rural Health Information Hub, nd). The strengths of this model are the ability to facilitate identification of the desired outcomes at the beginning of the planning process, which determines the evaluation metrics and the utilization of a ranking system which will then facilitate consideration of the determinants for change at individual, provider, and system levels allowing for the identification, development, and implementation of interventions with the greatest potential of achieving a positive impact (Phillips, et al., 2012).
PRECEDE stands for:
Predisposing
Reinforcing, and
Enabling Constructs in
Educational/environmental
Diagnosis and
Evaluation.
The PRECEDE phases correspond with steps 1 through 4 of the model
PROCEED stands for:
Policy
Regulatory, and
Organizational
Constructs in
Educational and
Environmental
Development
The PROCEED phases begin with steps 5 of the model
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Project Description and setting
Ongoing evidence based and best practices in the prevention of hemorrhage or external bleeding control is early transfusion of plasma and packed red blood cells (PRBC) and a global initiative called STOP THE BLEED which teaches external hemorrhage control (BleedingControl.org, nd). Protocols are in place within our hospital system which identify specific criteria to transfuse blood and blood products in the field. Another important aspect of external hemorrhage control, STOP THE BLEED education, has been offered throughout the healthcare system not only to educate hospital staff, but also to encourage staff to become instructors. Current system protocols and PI initiatives have given a head start on impacting external hemorrhage control and preventable deaths from trauma. Collaboration with neighboring EMS providers, will provide the education to ground medic crews regarding not only carrying plasma and blood, but also rapidly initiating the transfusion of these blood products per standing protocols. Collaboration with community leaders to facilitate STOP THE BLEED education, provided by members of the trauma team, and hosted at local schools and varying locations throughout the community. The goal in utilizing a quality improvement approach is to improve the public health issue of preventable deaths from trauma, more specifically deaths from hemorrhage caused by traumatic injury.
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Protocols currently within the system identifying criteria to transfuse in the field
Staff to obtain instructor training on STOP THE BLEED
Collaboration with local EMS to carry blood products and rapidly transfusing per protocol
Collaboration with community leaders to provide STOP THE BLEED education
Locations for STOP THE BLEED education provided by the hosting school, business, law enforcement agency, church, etc
recommendations
STOP THE BLEED education should be available to the public in all hospitals, schools, and law enforcement agencies
Bleeding control kits or tourniquets should be available in offices, schools, and other public buildings, and as easily accessible as an automated external defibrillator (AED)1
Figure 5: Stop The Bleed (Google Images, nd).Retrieved from https://static1.squarespace. com/static/ 59c410288fd4d26950aa959b/t/5a8f08ebec212df81184b51 /1516664675521
Stop+The+Bleed.jpg?format=1500w
(Navarro, 2016)1
Comprehensive evidence-based trauma prevention education, such as STOP THE BLEED, regarding bleeding control should be available to the public in all hospitals, schools, and law enforcement agencies. Bleeding control kits or tourniquets should be available in offices, schools, and other public buildings, and as easily accessible as an automated external defibrillator (AED) (Navarro, 2016). In a traumatic event, which are no longer rare occurrences, it is often necessary to buy time for victims to be transported to a facility that will provide definitive care for their traumatic injuries.
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conclusion
Over the last few decades, great strides have been made to improve the survivability of the victims of mass casualty events. Despite these efforts, the numbers of potentially preventable deaths from
traumatic injury continue to increase. While trauma care has improved in many areas, work is still needed to improve effective rapid initiation of pre-hospital care regarding external hemorrhage control. In the community in which I serve, our trauma facility sees over a thousand trauma visits a year. Many of those visits could have had better outcomes if early transfusion of plasma and (or) blood along with external hemorrhage control had been initiated in a timelier manner. Bystanders to a mass casualty event are a human resource that are underutilized, but can significantly impact the survival outcome of a victim suffering from a traumatic injury. Outreach and collaboration between Trauma services, sponsored by the Trauma Medical Center, and the leaders in the community will allow members of the trauma team to bring an evidence-based global initiative, STOP THE BLEED education and training, to teach the lay public proper bleeding control techniques, including how to use their hands, dressings, and
tourniquets to stem the flow of uncontrolled bleeding and increase the victim’s chance of survival. In addition we need to maintain positive relationships with our local EMS providers and share evidence-based education on carrying plasma and packed red blood cells (PRBC) on the ambulances. Early transfusion of plasma and packed red blood cells (PRBC) by pre-hospital medical providers is necessary to replace blood volume lost, prevent circulatory collapse, and significantly impact a hemorrhaging trauma patient’s survivability.
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Improve effective rapid initiation of pre-hospital care regarding external hemorrhage control
Early transfusion of plasma and (or) blood
STOP THE BLEED education and training
Bystanders can become immediate responders by performing critical external hemorrhage control
improve the survivability of the victims of mass casualty events
questions
Figure 6: Mountain of Marks (Google Images, nd). Retrieved from https://news.yahoo. com/2018-review-mountain-marks-152503660.html
References
Boston Marathon Bombing (Image), (Ken McGagh/MetroWest Daily News/AP, 2013). Retrieved from http://4.bp.blogspot.com/- G7VjHzBRMK8
/UW32xbHJFyI/AAAAAAABC4E/3h2OCfgC3-w/s1600/boston+bombings+Ken+McGagh+MetroWest+Daily+News.png
BleedingControl.org (nd). Retrieved from https://www.bleedingcontrol.org/about-bc
Centers for Disease Control (2019). Web-based Injury Statistics Query and Reporting System. Retrieved from http://www.cdc.gov/injury/wisqars.
Centers for Disease Control (2017). Global Health Protection and Security. Retrieved from https://www.cdc.gov/globalhealth/healthprotection
/ncd/about.html
Chang, R., & Holcomb, J. B. (2017). Optimal Fluid Therapy for Traumatic Hemorrhagic Shock. Critical care clinics, 33(1). pgs. 15–36. Retrieved from
doi:10.1016/j.ccc.2016.08.007
Crosby, R. & Noar, S. M. (2011). What is a planning model? An introduction to precede-proceed. Journal of public health dentistry 71(1). Pgs. S7-
s15.Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1752-7325.2011.00235.x
References cont’d_1
D’Andrea, W., Sharma, R., Zelechoski, A. D., & Spinazzola, J. (2011). Physical Health Problems After Single Trauma Exposure: when Stress Takes
Root in the Body. Journal of the American Psychiatric Nurses Association 17(6). Pgs. 378–392. DOI: 10.1177/1078390311425187.
Retrieved from http://www.traumacenter.org/products/pdf_files/JAPNA425187.pdf
Jacobs, J. M., & Joint Committee To Create A National Policy To Enhance Survivability From Intentional Mass Casualty Shooting events. (2015).
The Hartford Consensus III: Implementation of Bleeding Control. Bulletin of The American College of Surgeons. Retrieved from http://
bulletin.facs.org/2015/07/the-hartford-consensus-iii- Implementation-of-bleeding-control/
Mass Casualty (Google Images, nd) Retrieved from https://cdn.boundtree.com/assets/btm/University/Articles/ allresources/how-to-
practice-the-ems.jpg
Mountain of Marks (Google Images, nd). Retrieved from https://news.yahoo.com/2018-review-mountain- marks-152503660.html
References cont’d_2
Navarro, K. (2016). Public use of tourniquets, bleeding control kits. EMS Research Review. Retrieved from https://www.ems1.com/
ems-products/Bleeding-Control/articles/95472048-Public-use-of- tourniquets-bleeding-control-kits/
Officer Down/MCT Force Protection (Bing Images, nd) Retrieved from https://www.bing.com/images /search?view=
detaiv2&id=456639AE6BDAF5E C69F3BD8F0591F8AA686CF0E1&thid=OIP.ozPTyzls6MehYYTX2CbuPAHaE5& mediaurl=
http%3A%2F%2Fwww. Taconeconsulting. com%2Fwp- content%2Fuploads%2F2014%2FO2%2F02%2FDSC_ 0523jpg
&exph=3264&expw=4928&q=mass+ shooting+bleeding&selectedindex=90&ajaxhist=0&vt=0&eim=1,2,6
Phillips, J. L., Rolley, J. X., & Davidson, P. M. (2012). Developing Targeted Health Service Interventions Using the PRECEDE-PROCEED
Model: Two Australian Case Studies. Nursing Research and Practice, 2012. Pgs. 1-8. Retrieved from https://doi.org/10.1155/
2012/279431.
References cont’d_3
Rural Health Information Hub (nd). Rural Health. Retrieved from https://www.ruralhealthinfo. org/toolkits/health- promotion/2/program-
models/precede-proceed
Spinella, P. C. (2017). Zero preventable deaths after traumatic injury: An achievable goal. Journal of Trauma Acute Care Surgery 82(6). Pgs. S2-S8.
Retrieved from https://rdcr.org/wp-content/uploads/2018/05Spinella-Zero-preventable-deaths-after-traumatic-injuries-J-Trauma-vol-
82-N-6-Supplement-1.pdf
Stop The Bleed (Google Images, nd). Retrieved from https://bdn-ss-tc.s3.amazonaws.com/uploads/2019/06/Stop-the-bleed- 640x400.jpeg
Stop The Bleed (Google Images, nd).Retrieved from https://static1.squarespace.com/static/squarespace.com/ static/59c410288fd4D269
50AA959B/T/5A8F08EBEC212DF 81184b51d/1516664675521/ Stop+The+Bleed.jpg?format=1500w
Williams, P. (2019). Turning Bystanders Into First Responders. The New Yorker. Retrieved from https://www.newyorker.com/magazine/2019/04/
08/turning-bystanders-into-first- responders
References cont’d_4
Warren, S. (2019). White Paper. Unpublished manuscript, University of Texas Arlington.
Warren, S. (2019). Quality Matters Needs Assessment manuscript. Unpublished manuscript, University of Texas Arlington.
The end
Figure 7: Stop The Bleed (Google Images, nd). Retrieved from https://bdn-ss-tc.s3.amazonaws.com/uploads/2019/06/Stop-the-bleed-640x400.jpeg
