CIREN The Nation's Largest Learning Laboratory
The Crash Injury Research and Engineering Network (CIREN) is a multi-center research program involving a collaboration of clinicians and engineers in academia, industry, and government. Together, they are pursuing in-depth studies of crashes, injuries, and treatments to improve processes and outcomes. CIREN's mission is to improve the prevention, treatment, and rehabilitation of motor vehicle crash injuries to reduce deaths, disabilities, and human and economic costs.
SAN DIEGO CIREN CENTERCOMMITMENT The San Diego CIREN center is committed to saving lives, and mitigating and preventing serious injuries. CIREN is in a unique position to accomplish these goals through multidisciplinary review of motor vehicle crashes. It is able to identify how injuries occur and how they may be prevented either by changes in engineering design or occupant safety education. These primary prevention actions will decrease the occurrence of injuries and reduce their severity. Additionally, CIREN findings can be utilized to limit injury sequelae by improving triage, transport and treatment of motor vehicle crash (MVC) occupants. CIREN identification of injury patterns stratified by crash configuration, is provided to prehospital providers and nurses and physicians responsible for making triage and transport decisions for victims of MVCs. The CIREN research can then be used to assist in the early medical treatment of these patients.
INTRODUCTIONThe San Diego region is rich in diversity. San Diego County, the fifth largest county in the United States, is home to 2.8 million residents and approximately 1.8 million licensed drivers. Covering 2.7 million acres, San Diego County has over 7,700 miles of roadways, 600 miles of which is made up of state highways. San Diego County is bordered by the Pacific Ocean to the west, Camp Pendleton to the north, the Anza-Borrego desert to the east, and the U.S.-Mexico border to the south. These boundaries insulate San Diego from adjacent regions thereby becoming a natural laboratory for research. In fact, because San Diego has highly urbanized areas as well as rural areas the CIREN team is exposed to a wide range of crash configurations, from T-bone crashes in red light running cases to potential delayed notification for crashes occurring in the less densely populated areas.
TRAUMA SYSTEM PARTICIPATIONThe San Diego CIREN Center is a collaborative effort between the six regional Trauma Centers and the County of San Diego, Health & Human Services Agency, Division of Emergency Medical Services. The unique configuration of the San Diego CIREN program, incorporating six hospitals rather than one, presents logistical challenges for its participants but also offers research outcomes rich in rewards.
The CIREN Program was established in 1996 through the General Motors Corporation settlement agreement and is currently underwritten through a Cooperative Agreement with the NHTSA.
The Principal Investigators for the project are:
- Raul Coimbra, MD, PhD, Chief, Division of Trauma/Surgical Critical Care/Burns UCSD Medical Center - Gail Tominaga, MD, Co-Principal Investigator
Other key personnel include:
- Les Gardina, RN, MSN, PHN, CEN Program Manager - Steven M. Erwin, Crash Investigator - Carol Conroy, PhD, Epidemiologist
The Principal Investigators and program coordinators are supported by the Trauma Medical Directors and nurse administrators, researchers and case managers at the county’s trauma centers. The participating Trauma Centers are: - Rady's Children’s Hospital and Health Center, San Diego (Pediatric Center) - Palomar Medical Center - Scripps Mercy Hospital - Scripps Memorial Hospital – La Jolla - Sharp Memorial Hospital - University of California San Diego (UCSD) Medical Center
The San Diego CIREN program benefits from a more than twenty-year working relationship with the San Diego Trauma System. The trauma system partners include the six Trauma Centers, the Division of Emergency Medical Services (EMS) and the Office of the Medical Examiner. Established in 1984, San Diego’s trauma system is nationally recognized for its pioneering efforts, not only in patient care, but for its integration between EMS and Public Health and its strides in quality improvement activities. Personnel from the County of San Diego, Emergency Medical Services provide administrative and managerial oversight to the CIREN project. The trauma system participants have engaged in collaborative efforts to improve the triage, transport and treatment of injured patients, including motor vehicle crash occupants.
QANet Quality Collector System (QCS)In addition to their participation in the Trauma System, EMS has on-line access to all prehospital provider data. Housed in the office of EMS is a wide area network computer system, linking prehospital providers with Emergency Departments in a real time prehospital patient information system identified as the QCS.The San Diego CIREN system uses the QCS to assist personnel in identifying potential candidates. The QCS is queried daily to track all MVC patients transported to one of the six trauma centers. This data is forwarded to the nurse managers at each trauma center and they use it as a guide to screen patients. Information is maintained in a database and evaluated for exclusion criteria and since 1999 the San Diego CIREN Center has screened over 17,000 MVC transports. Not all exclusion reasons are tracked for every patient. Once it has been discovered the occupant does not meet criteria, the reason is entered into the database. For example, if the patient is transported to the Emergency Department (ED) and discharged, it is apparent the severity of injury is not adequate for study entry. This is reflected in Table 1 in the Minor Injury category which includes discharges from the ED as well as patients who do not have Abbreviated Injury Scores (AIS) of three or greater.
PREHOSPITAL TRANSPORTThe County of San Diego Division of Emergency Medical Services (EMS) is the primary regulatory agency for the local integrated emergency medical services (EMS) system. EMS coordinates activities of prehospital and trauma care services for San Diego County residents and visitors. County ambulance service providers respond to more than 250,000 calls annually. There are more than 6,000 emergency medical technicians (EMT-Is), defibrillation personnel (EMT-Ds), paramedics (EMT-Ps), and mobile intensive care nurses (MICNs) in San Diego County. The EMT’s are employed by advanced life support (ALS) ambulance providers (17), including air medical providers and basic life support (BLS) ambulance providers (15). Prehospital transports are directed to one of 24 emergency receiving hospitals including trauma centers (6) and base hospitals (8).
Helicopter transfer is an important means of transport in San Diego County for victims of motor vehicle crashes. Crashes in rural areas, involving seriously injured patients or patients with a high risk for occult injuries often utilize the county’s helicopter service to expedite transport to a trauma center. The County of San Diego protocol requires a first responder to evaluate the occupants and crash dynamics before a helicopter can be dispatched. In San Diego the first responders are well trained and arrive at a decision quickly. The problem arises if there is a delay between the time of the crash and the time of crash discovery. These situations would benefit enormously from the Automatic Crash Notification (ACN). Additionally, in some rural areas in the United States, where first responders may be volunteers, the level of education regarding crash configurations and risk of occult injury may not be equal to full-time professionals.
DETECTION AND ANALYSIS OF EMERGING INJURY PATTERNSSince 1997, San Diego CIREN has enrolled over 450 patients. Ninety percent of occupants survived; however, 10% died from their injuries received in the crash. For those who died, 60% died at the crash site, 18% died in the trauma center Intensive Care Unit, 7% died in the trauma center operating room, 5% died in a resuscitation room (other than the emergency department), and less than 3% each died in the emergency department, radiology, hospital floor, or another hospital. Age of the injured occupants ranged from less than one year old to over 90 years old. Over half of occupants were between 20 and 49 years of age. Almost 4% were children 10 years or younger and almost 3% were 80 years or older. The mean age was 40 years. There was an almost even distribution of gender with slightly more females (51%). Most (77%) of the injured occupants were drivers and 17% were passengers seated in the outboard right position in the front seat. Almost all occupants had multiple injuries of at least AIS 2 (moderate) severity. Fifteen percent of injured occupants had 10 or more documented injuries of at least AIS 2 (moderate) severity. Almost 35% of all injuries involved the lower extremities. However, the head and thorax each accounted for about 15% of the injuries. Although 59% of cases had a moderate injury (AIS 3) as their most severe injury, 19% had serious (AIS 4), 10% had critical (AIS 5) injuries and 3% had maximum (AIS 6) severity injuries. The Injury severity Score ranged from 4 to 75. About 25% occupants had an ISS greater than 49, indicating these were severely injured persons. Almost 80% of CIREN cases were using manual safety belts at the time of the crash, but only about half were documented to be wearing their safety belts properly. All vehicles involved in these crashes had at least a single frontal airbag on the driver’s side but some had multiple air bags in varying vehicle locations. Of the airbags available to deploy in a crash, 68% deployed during the crash. The CIREN database is specifically designed to study persons severely injured in motor vehicle crashes. Although case collection involves all trauma centers within the County, not all injured occupants agree to participate in the CIREN Program. Therefore, these results may not be representative of all occupants in motor vehicles crashes or even crashes within San Diego County. San Diego CIREN researchers continue to analyze these data to gain further information about motor vehicle related injuries. This information can then be used to help determine how vehicles, safety systems, and federal motor vehicle safety standards can be modified to prevent serious injury and death.
OUTREACH EFFORTS FOR THE PREHOSPITAL AND MEDICAL COMMUNITYIn keeping with the NHTSA and CIREN goals of reducing the incidence of mortality and morbidity from motor vehicle crashes, San Diego has stepped-up its efforts to bring CIREN findings to the professionals who take care of MVC victims. Making triage decisions regarding appropriate transport destination is key to saving lives and ensuring that medical treatment will result in the best possible outcome. Initially, CIREN impacted transport guidelines by providing input to a countywide task force responsible for determining triage guidelines for all prehospital providers and Emergency Department personnel. The CIREN crash investigator provided education to task force members resulting in the adoption of a triage algorithm incorporating intrusion and deformation parameters. The triage guidelines assist personnel in determining whether the MVC occupants require the resources of a trauma center.
To reinforce the new triage guidelines, CIREN personnel conducted outreach reviewing the specifics of the new policy. Included in the presentations were digital images of vehicles depicting intrusion and deformation matching the countywide criteria as well as the injuries associated with the specific vehicle damage. Prehospital providers vocalized their interest in the presentation topics because they related to their everyday work and helped explain the source of injury patterns they observed in their professional practice. CIREN also used these forums to provide information about specific crash configurations and the corresponding occupant kinematics. Research findings were presented including occult liver/spleen injuries associated with shoulder belt-only crashes, examples of occult aortic injuries, and side airbag protection systems.Other areas of emphasis include occult injuries often encountered in offset frontal crashes with shoulder belt only use. This knowledge can assist providers in choosing the correct transport destination and assist treating physicians with quickly diagnosing the injuries.
Education regarding "double impacts" has met with a favorable response. Prehospital personnel, assessing the scene of a crash, may be lulled into believing an occupant’s injuries are less severe because they identify that an airbag has deployed. However, if the first impact was of sufficient magnitude to deploy the airbag and a second impact was encountered during the crash, the occupant may have had less protection (if a seatbelt was used) or no protection (if a seatbelt was not used) at the time of the second impact.Prehospital personnel are also reminded that unbelted backseat occupants can easily load front seat occupants in frontal crashes potentially increasing the injury severity.San Diego CIREN has also incorporated information regarding the proper use of child restraint systems. A CIREN participant has worked on a statewide committee to incorporate child seat information on the California EMS Authority web page, encouraging prehospital providers to become involved in injury prevention activities for pediatric motor vehicle occupants.
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