OPERATIONS THROUGHPUT AS A DETERMINANT OF GOLDEN-HOUR IN MASS-GATHERING MEDICINE
Golden-hour, a time-tested concept for trauma-care, involves a systems approach encompassing healthcare, logistics, geographical, environmental and temporal variables. Golden-hour paradigm in mass-gathering-medicine such as the Hajj-pilgrimage entwines along healthcare availability, accessibility, efficiency and interoperability; expanding from the patient-centric to public-health centric approach. The realm of mass-gathering-medicine invokes an opportunity for incorporating operations-throughput as a determinant of golden-hour for overall capacity-building and interoperability.
Golden-hour was evaluated during the Indian-Medical-Mission operations for Hajj-2016; which established, operated and coordinated a strategic network of round-the-clock medical operations. Throughput was evaluated as deliverables/time, against established Standard-Operating-Procedures for various clinical, investigation, drug-dispensing and patient-transfer algorithms. Patient encounter-time, waiting-time, turnaround-time were assessed throughout echeloned healthcare under a patient-centric healthcare-delivery model. Dynamic evaluation was carried out to cater for variation and heterogeneity.
Massive surge of 3,94,013 patients comprising 2,25,103 males (57.1%) and 1,68,910 females (42.9%) overwhelmed the throughput capacities of outpatient attendance, pharmacy, laboratory, imaging, ambulance, referrals and documentation. There was delay in attendance, suspicion, diagnosis and isolation of patients with communicable infections. The situational-analysis of operations-throughput highlights wasted turnaround-time due to mobilization of medical-team, diverting critical healthcare resources away from emergency situations.
Time being a crucial factor in the complexity of medical-care, operations-throughput remains an important determinant towards interoperability of bottlenecks, thereby being a determinant of golden-hour in mass-gathering-medicine. Early transportation of patient to definitive-care reduces treatment initiation-time, notwithstanding logistics of communication, evacuation, terrain and weather being deterministic in outcome. Golden-hour needs to be emphasized under a population-based approach targeting the clientele towards administering first-aid and reaching out to hospital within the golden-hour.
Kollek D. An intro to mass gatherings. Centre for Excellence in Emergency Preparedness. Ontario-Canada, Jun 2014: 1-15. www.ceep.ca/publications/Mass_Gatherings.pdf
WHO. Epidemic and Pandemic Alert and Response. Communicable Disease alert and response for mass gatherings. WHO/HSE/EPR/2008/8 Technical Workshop. Geneva-Switzerland, 29-30 Apr 2008:1-29. http://www.who.int/csr/mass_gathering/en/
Memish ZA, Stephens GM, Steffen R, Ahmed QA. Emergence of medicine for mass gatherings: lessons from the Hajj. Lancet Infect Dis. 2012 Jan;12(1):56-65. http://www.ncbi.nlm.nih.gov/pubmed/22192130
Shujaa A, Alhamid S. Health response to Hajj mass gathering from emergency perspective, narrative review. Turk J Emerg Med. 2015 Dec; 15(4): 172–176. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882208
Mück F, Wirth K, Muggenthaler M, et al. Pretreatment mass casualty incident workflow analysis : Comparison of two level 1 trauma centers. Unfallchirurg. 2016 Aug;119(8):632-41. http://www.ncbi.nlm.nih.gov/pubmed/27351989
Dinh MM, Bein K, Roncal S. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury. 2013 May;44(5):606-10. doi: 10.1016/j.injury.2012.01.011. http://www.ncbi.nlm.nih.gov/pubmed/22336130
van Zanten AR. The golden hour of antibiotic administration in severe sepsis: avoid a false start striving for gold. Crit Care Med. 2014 Aug;42(8):1931-2. doi: 10.1097/CCM.0000000000000363. http://www.ncbi.nlm.nih.gov/pubmed/25029127
Heled Y, Rav-Acha M, Shani Y, Epstein Y, Moran DS. The "golden hour" for heatstroke treatment. Mil Med. 2004 Mar;169(3):184-6. http://www.ncbi.nlm.nih.gov/pubmed/15080235
Wyen H, Lefering R, Maegele M, et al. The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15103 patients from the TraumaRegister DGU(R). Emerg Med J. 2013 Dec;30(12):1048-55. doi: 10.1136/emermed-2012-201962. http://www.ncbi.nlm.nih.gov/pubmed/23258373
Vanderschuren M, McKune D. Emergency care facility access in rural areas within the golden hour?: Western Cape case study. Int J Health Geogr. 2015; 14: 5. doi: 10.1186/1476-072X-14-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4305393
Meskere Y, Dinberu MT, Azazh A. Patterns And Determinants Of Pre-Hospital Care Among Trauma Patients Treated In Tikur Anbessa Specialized Hospital, Emergency Department. Ethiop Med J. 2015 Jul;53(3):141-9. http://www.ncbi.nlm.nih.gov/pubmed/26677524
Khan ID, Basu A, Trivedi S, Prasad M, Rappai TJ, Narayanan RV, Ramphal SK, Singh NS. Battlefield, Bullets and Bugs: The vicious Circle in Gunshots. J Basic & Clin Med 2016, 5(1): 11-12. www.sspublications.org/index.php/JBCM/article/view/65
Khan ID. Extreme Altitude Pulmonary Oedema in Acclimatized Soldiers. MJAFI 2012; 68 (4): 339-345. (PMID – 24532901) (Citations -4)
Khan ID. Comorbid Cerebral and Pulmonary Edema at 7010 M/23000 Ft: An Extreme Altitude Perspective. J Medicine 2013, 14(2): 153-155.
Khan ID. Cerebral Venous Sinus Thrombosis (CVST) Masquerading as High Altitude Cerebral Edema (HACE) at Extreme Altitude (6700 m/22000 ft).Int J Travel Med Glob Health. 2016, 4(3): 65-67.
Kotwal RS, Howard JT, Orman JA, et al. The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. JAMA Surg. 2016 Jan;151(1):15-24. doi: 10.1001/jamasurg.2015.3104. http://www.ncbi.nlm.nih.gov/pubmed/26422778
Lerner EB, Moscati RM. The golden hour: scientific fact or medical "urban legend"? Acad Emerg Med. 2001 Jul;8(7):758-60. http://www.ncbi.nlm.nih.gov/pubmed/11435197
Platts-Mills TF, Evans CS, Brice JH. Prehospital Triage of Injured Older Adults: Thinking Slow Inside the Golden Hour. J Am Geriatr Soc. 2016 Aug 24. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/27556573
Samplais JS, Lavoie A, Williams JI, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma. 1993;34:252–261. http://www.ncbi.nlm.nih.gov/pubmed/8459466
Khan ID, Gupta N, Rangan NM, Singh R, Sharma AK, Khurana A, Rudra P, Krushnarao MS. Evaluation Of Pre and Post Analytical Variables in Clinical Microbiology Services in Multidisciplinary ICU of a Medical College And Tertiary Care Hospital. J Basic & Clin Med 2016, 5(1): 2-4. www.sspublications.org/index.php/JBCM/article/view/63
Khan ID, Sahni AK. Rapid Diagnosis of Dengue Outbreaks in Resource Limited Facilities. West Indian Medical Journal. 2016. E-pub ahead of print. 10:7727/wimj.2016.095
Ahmed QA, Barbeschi M, Memish ZA. The quest for public health security at Hajj: the WHO guidelines on communicable disease alert and response during mass gatherings. Travel Med Infect Dis. 2009 Jul;7(4):226-30. http://www.ncbi.nlm.nih.gov/pubmed/1917105
Newgard CD, Schmicker RH, Hedges JR, et al. Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Ann Emerg Med. 2010 Mar; 55(3): 235–246.e4. doi: 10.1016/j.annemergmed.2009.07.024. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008652
Turkestani A, Balahmar M, Ibrahem A, Moqbel E, Memish ZA. Using health educators to improve knowledge of healthy behaviour among Hajj 1432 (2011) pilgrims. East Mediterr Health J. 2013;19 Suppl 2:S9-12. http://www.ncbi.nlm.nih.gov/pubmed/24673092
Mandourah Y, Ocheltree A, Al Radi A, Fowler R. The epidemiology of Hajj-related critical illness: lessons for deployment of temporary critical care services. Crit Care Med. 2012 Mar;40(3):829-34. http://www.ncbi.nlm.nih.gov/pubmed/22080635
Memish ZA, Assiri A, Turkestani A, Yezli S, Al Masri M, Charrel R, et al. Mass gathering and globalization of respiratory pathogens during the 2013 Hajj. Clin Microbiol Infect. 2015 Jun;21(6):571.e1-8. http://www.ncbi.nlm.nih.gov/pubmed/25700892
Taghavi S, Vora HP, Jayarajan SN. Prehospital intubation does not decrease complications in the penetrating trauma patient. Am Surg. 2014 Jan;80(1):9-14. http://www.ncbi.nlm.nih.gov/pubmed/24401498
Jacob M, Kumar P. The challenge in management of hemorrhagic shock in trauma. Med J Armed Forces India. 2014 Apr;70(2):163-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017195
Jindal AK, Pandya K, Khan ID. Antimicrobial Resistance: A public health challenge. Med J Armed Forces India 2014; 71 (2): 178-181. http://www.ncbi.nlm.nih.gov/pubmed/25859082
Khan ID, Sahni AK, Bharadwaj R, Lall M, Jindal AK, Sashindran VK. Emerging Organisms in a Tertiary Healthcare Set Up. Med J Armed Forces India 2014; 70 (2): 120-128. http://www.ncbi.nlm.nih.gov/pubmed/24843199
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