Ap ka Razakar

Primary health care is the cornerstone of health care systems which meets the person’s physical, mental, and social health needs. Primary health care attends not only to individuals and families but also to the well-being of communities and their populations. Focus has been on improving primary health care everywhere but during this process the health of the main breadwinner of the house on whom the livelihood of many depends is grossly neglected, and if unfortunately one is stuck with such a calamity requiring emergency assistance such as Road Traffic Accident (RTA), are they getting the care they need. 

Each year approximately 50 million people are affected by road traffic accidents and 1.2 million people die from it. According to the Global Burden of Disease Study, road traffic injuries are estimated to become the third leading cause of lost disability-adjusted life years (DALYs) by 2030.  

Pakistan is the fifth most populated country globally with an estimated population of over 220 million and according to 2017 World Health Organization data on road traffic deaths shows that RTAs unfortunately reached 27,081 or 2.22% of total deaths in Pakistan. The Global Status Report on Road Safety as well as the world report on RTI, both has identified setting up surveillance systems as important in Low to Middle income countries for road safety. 

The COVID 19 pandemic has shown the role of smart phone mobile apps and internet for creating awareness and providing real time data information regarding coronavirus cases and tracking their spread, similar work could be done for RTA surveillance  by mobile app to monitor EMS services responses and evaluate their services. The first hour after any emergency known as the "Golden Hour" is vital for the life or death of a patient and can be the difference between a minor or severe outcome of his health. 

Unfortunately Ambulance services are not strictly regulated in our country and there is a huge gap in tracking the data about EMS pre-hospital services such as what number of trained health care workers are there, what first aid equipment apart from a stretcher does the ambulance have and any medicines etc. 

The main concept came from previous studies done on setting up an urban RTA surveillance system, which identified the need to develop a cheap and sustainable surveillance system by using a mobile app via smartphone to raise awareness regarding road safety and keep track of EMS responses. Unfortunately a centralized emergency call service does not exist in the country,  and with multiple ambulance services active in the country, there is no uniform data on how these services are performing as a pre-hospital first responder organization and what standards of care are followed. There is a need to centralize the services to help optimize the response time and integrate them together with nearby trauma centers. 

A working model of RTA surveillance system is been pilot tested in Karachi using novel smart phone technology and integrating it with the trauma center registry where possible. We propose expanding our Karachi city's project across the country after the pilot testing is done. The surveillance system developed via the mobile app will assess the condition of the road traffic flow as used by google maps and  a centralized command center will direct nearby ambulances to arrive timely at the RTA site to assist the victims.

We also plan to link EMS service with updated technological software systems using personalized digital assistant (PDAs) similar to a smartphone for active surveillance on these ambulances. We hope to integrate the mobile app initially into Ambulances and Emergency services centers (via PDAs) and for the general public volunteers via smartphones. This will not only collect data but show performance indicators for emergency services such as assessing the time taken by the response team which will be collected, analyzed, and shared with stakeholders. The EMS response time has reduced from 13 to 8 minutes over the years as reported in a Karachi study but no data on improvement in national emergency response time is available and this is vital if we want to make use of the first golden hour of the matters as a performance indicator for urgent informed decisions in crisis. While not all emergency responses require urgent response, timely decisions are important for effective resource management and patient care which can be analyzed by this national data to assess whether standards of care are met. 

The Prime Minister recently launched the life-saving CPR (Cardiopulmonary resuscitation) Training Campaign under the Strategic Reforms section of the government which opened registration for the general public for training to become a lifesaver as ‘Prime Minister’s Life Saver’ by calling at 1166. We have also proposed to train Ambulance personnel and volunteers on CPR as well and, this new initiative will help us develop a more centralized command center for EMS calls. In addition, we plan to use telemedicine to provide on-site medical consultations to EMS staff especially in remote areas where highly specialized experts are not available. 

In our solution we will test the mobile app for three years in different cities as emergency services standards of care are different in different places. 

In the future the prototype showed in the video clip will be upgraded and improved to include fire stations and hospital emergency centers for an integrated nationwide service solution covering pre-hospital and in-hospital emergency care.

Road Traffic Accidents are a growing health burden internationally, and such emergencies poses an enormous health and economic impact on millions of people, particularly in low- and middle-income countries. Barriers such as proper first respond, lack or delay of access to standard care, insufficient availability, and inconsistent quality of care is a matter of life or death to these people and could be the difference for them from living healthy and productive lives impacting them and their families. 

RTAs cost the Pakistani economy around 1.5 billion US$ each year and studies have identified emergency medical interventions as some of the most cost-effective measures in RTAs. Availability of quality volunteer pre-hospital care/ambulance services is the second most cost-effective public health intervention reported. Every two out of five Pakistani RTA patients with a moderate injury, even when not admitted spends over five times more on healthcare costs as compared to a mildly injured patient. These results clearly point to the socioeconomic benefit of better injury prevention, control and care strategy in Pakistan which can reduce the enormous costs borne by patients and their families. 

Data generated from information stored in cloud servers with an advanced level of technology, will help report the risk prediction and degree of injury from RTAs in the future. 

Our research team comprises of members from multidisciplinary fields across the country which is key for this project’s success starting with Information Technology and Telecom (Development of Mobile App already done), over to Urban Planning (Implementation and Testing in major Cities) and ends with Public Health Surveillance and Epidemiology (Data analysis and integration of App with awareness programs) as proposed in this solution. The researchers have rich experience in artificial intelligence, software development, machine learning, hospital administration and management, epidemiology and public health surveillance. They share common interest in integrating information technology with various public health issues and here they are working on the challenge to develop a public health surveillance system using mobile app for rapid response to emergency and road safety/injury prevention leading to better pre-hospital emergency care.

We have assembled a group of IT experts, engineers and public health researchers interested in road safety and injury prevention across Pakistan. Starting in Sindh where the pilot testing of the mobile app is been done in the largest city, Karachi of the country from funding by the Higher Education Commission, Pakistan by DUHS, we have 2 partners, one at Liaquat University of Medical & Health Sciences (LUMHS) in Jamshoro and another at Department of Public Health, Faculty of Life Sciences, Shaheed Zulfikar Ali Bhutto Institute of Science and Technology [SZABIST] in Karachi.  

Simultaneously in Baluchistan, our partner at the Civil Provincial Hospital (SPH) in Quetta along with the Medical Director will coordinate the activities in Quetta and its surroundings.

In Punjab, the largest province of the country our partner is at Department of Public Health, University of Health Sciences in Lahore and will be looking at the project across the province. University of Health Sciences has many teaching hospitals and medical colleges affiliated with it across Punjab and it will play a key role in linking the selected cities across Punjab.

Finally in Khyber Pakhtunkhwa (KPK), we have a partner at the Department of Public Health & Social Sciences, Khyber Medical University and has worked on Injury prevention projects, and is well placed to spearhead our project across KPK from Peshawar into the province. 

The barriers that we hope to overcome with this grant are described below.

We have secured funding for pilot testing in Karachi but unfortunately have not acquired funds needed to expand this project to monitor the mobile app and provide first aid CPR training in different cities for three years across the country. The recent Prime Minister's initiative of the life-saving CPR (Cardiopulmonary resuscitation) Training Campaign is something we can capitalize on. There is no age and gender restriction on becoming a trainer under the campaign, and CPR will be included in curriculum at school level while training every citizen. This aids our vision to have potentially as many as possible trained volunteers and Ambulance personnel on first aid training through the mobile application. 

Funding is needed for setting up the infrastructure across the country and linking with ambulance call centers who will immediately forward messages to designated ambulances via pager and/or phone. The transmitted data will also identify whether a BLS or ALS ambulance is needed. Further, the smart phone web application combines location tracking services such as GPS with CCTV where available for store in cloud server, other visualization tools on social media and mobile services technologies will capture incident reports/records to be combined in list, map and detailed information via a user-friendly interface across the nation. Overall supervision will be by our academic and research partners who have agreed to be part of this consortium and will help in faculty capacity building of less research intensive partners. 

We with our partners especially those in EMS organizations will help to develop and organize first aid training workshops as well as become part of the PM life Saver campaign by creating first aid awareness programs for the public via social media through the app. Feedback from various sectors regarding pre-hospital emergency services performance as well as efficacy of the RTA app would be highly appreciated to update the app and improve EMS services accordingly.

Considering our cultural and socioeconomic values, as well as the support given by philanthropists and donor agencies to emergency services in Pakistan, we are confident that  after seeing the benefits of the app for three years, the public will realize the importance of first aid and CPR training as well as the utility of such a surveillance system as proposed by us. 
Our pilot project in Karachi will give us confidence in translating it at the broader national level and give benefit to a greater number of resource constraint people involved in emergency crisis.
There is potentially no identified market barrier, and the success of this project will attract long term marketing ads especially from motor and transport industry. Also periodic  governmental initiatives such as the PM CPR campaign will help convince our policymakers to initiate such solutions in the public health care system. 

The first digital based trauma registry in Pakistan, known as Karachi Trauma Registry (KITR) was developed in 2006 with a 24 hours surveillance system setup in five hospitals. Unfortunately, this closed after a decade due to non-integration of data from multiple sites. 

Our solution adapts from the successful mobile based digital model from other business sectors such as home delivery and transport apps to use this digital advancements in improving transport and medical care for RTA victims, training/education sessions of EMS, and first aid emergency services awareness for the general public. Connecting people through these smartphones applications using artificial intelligence will provide meaningful information, and interaction in real time emergency situations which will allow faster access that was not previously possible. 

Cloud server computing allows for easily accessible software applications in multiple places and data over the web such as seen in specific information services such as search engines for weather, maps and traffic control etc. Updated information about the road conditions and dispatch resources will be accumulated and made readily available for speedy transport of RTA victim through ambulances to emergency departments in nearby hospitals to make use of the golden hour to save the patients. The integration of the mobile app with smartphones will be done simultaneously to organize CPR trainings for public volunteers and data analyzed at periodic intervals will be sent for review with relevant stakeholders.

After three years of using the app and the public awareness campaign through the social media, and direct interaction will bring behavior change and road safety in the community. Use of social media to educate the public on first aid training and importance of CPR will be compounded by such initiatives such as the PM life saver CPR program which will help get support from governmental quarters to sustain the app.

The development of the CPEC corridor has increased the mass road transportation across Pakistan  exponentially and resulted in more RTAs and related deaths until preventive measures are put in place. 

Thus surveillance systems as well as road safety measures need to be in place before this happens to reduce the anticipated future RTA burden. The surveillance system can only be successful if the RTA victims are located rapidly and immediately rushed via ambulance to the relevant nearest trauma center to reduce mortalities. 

With funding secured from Higher Education Commission of Pakistan this app will be pilot tested in Karachi, the largest city of the country, our solution is to expand this to be tested in all major cities of Pakistan for implementation of the automated mobile app. 

Once this active surveillance mobile app is tested in major cities by our solution we plan to integrate and launch it as a nationwide application, for this purpose we are building on collaborations to further establish research partnerships and develop a consortium of researchers within Pakistan with academic , research and industrial partners who are interested in road traffic safety and injury prevention with the aim to build a force of highly-trained medical doctors and researchers proficient in life-saving skills and disaster management, that can respond to emergent situations and have a futuristic goal of having a Mass Disaster Task Force. 

We propose to reduce the burden and fatalities of RTIs by time-sensitive EMS response via a Mobile app which provides GPS location and contact to the RTA victims. Our proposed project will target the Sustainable Development Goals 3, 11 and 16 and our focus is Sustainable development goal 3 specifically targeting 3.6 which states: “By 2020, halve the number of global deaths and injuries from road traffic accidents”. Although we would not be able to achieve this target setting up an active surveillance system accessible to first aid volunteers would be the first step in the right direction to improve the system.

Specifically some of the measurable indicators will be 

• Number of registered volunteers with first aid training
• Number of Ambulance and EMS health care providers trained for CPR program.
• Trust and use of 24 hours centralized emergency helpline.
• Feedback on satisfaction and via the data generated from the cloud server.
• Reduction of RTA mortalities and morbidities.
• Reduced numbers of RTA related long term complications.

Karachi is the largest city of Pakistan and the financial, industrial and trade capital of Pakistan with many government and private sector hospitals. There are many private ambulance services in the city most of which are unable to provide more than a taxi service with a stretcher. Although ambulance personnel have undergone some trainings in the past, there is a need to immerse EMS services with digital technology enabled mobile apps and via  on-line teaching sessions. 

For this purpose we hope our pilot testing of the locally developed mobile app will lead to cost effective digital technology and wireless based cloud storage will bring major advancement via integrated use of smartphones and applications to allows people to connect with each other, share meaningful information, and communicate in real time. These advantages of combing digital technology will be used during the pilot testing of the RTA mobile app as newer digital technologies provide easier, and accessible powerful digital capabilities and connects people digitally and socially more than ever. 

The project has three stages with the first stage already funded by Higher Education Commission of Pakistan and funds requested for second and third stages. 

 Stage 1: Concept and development of Mobile application (Funded by Higher Education Commission, Pakistan, Pilot testing to be done in Karachi)

 Stage 2: Use of Social Media as Intervention: 

Social media engagement: In addition to Mobile App, the behavioral component of the RTA app will also engage social media (such as Facebook, WhatsApp and Instagram) as well as link via our developed mobile app to educate the general public about road awareness and safety, risky behaviors, changes in legislation, and updating them on latest statistics and research findings on road traffic accidents and its impact on individuals and communities. 

Integration of Technology with EMS: The future success of the RTA digital technology requires the integration of smart phone technology with emergency services for full efficiency and utilization of EMS. This has to be done across Pakistan since the emergency surveillance services are varied in various places by type of operations and response in different cities.   

Stage 3: Testing and revision of Mobile application to the General Public: 

Updating of the mobile app by trouble shooting and revision of mobile application will be done if needed after use by the general public across the country. We may require further funds to expand it nationwide from selected cities.  

Also, large scale implementation of public awareness road safety program via social media will be done. Implementation of road safety mobile app and marketing strategies to secure sustainable long term funding via marketing ads will also be done such as integration with the PM's CPR training program. 

Emergency medical services deal with patients in “pre-hospital and out-of-hospital” environments. The need to dispatch the right ambulance to the emergency is most important. The smartphone app will rapidly transmit the information to the ambulance call center which will immediately forward messages to designated ambulance. The transmitted data will identify whether a BLS or ALS ambulance is needed and the smart phone web application will combine location tracking services such as GPS with cloud based storage for accurate and speedy arrival at emergency site. This quality care service will be appreciated by the users.

There are at least five institutions involved across four provinces in selected cities and the RTA surveillance will require the engagement of stakeholders at the level of the  ambulance services and auxiliary health staff at the pre-hospital stage, one must remember that the emergency services at the hospital or trauma centers are beyond the scope of evaluation of performance indicators here as we are focusing on primary health care related to emergency services such as first aid responders.

In our solution, the role of the mobile application will be revised and updated as details of the actual implementation process of the RTA surveillance system comes in and we are able to assert the hindrances and barriers to the system. Mobile  application is only a tool and will act as a surveillance system only if implementation process and the role of the personnel involved in surveillance is clearly defined.

Since the conceptualization and development of mobile apps made possible with recent digital technology and wireless based cloud storage, ideas that might bring major advancement in healthcare systems have bloomed. The advantages of combing technology will be used by the RTA mobile app model to provide accessible powerful digital capabilities, connecting people digitally and socially that was previously not possible.

Updated information about the road conditions and dispatch resources will be accumulated and made readily available to ambulances for speedy transport of RTA victim to emergency departments in nearby hospitals. 

The project has two main phases. The initial phase has been initiated which involves developing the mobile app with our IT partners and pilot testing in Karachi. For this solution we are testing in selected major cities across Pakistan to study integration with EMS services such as ambulances and hospital departments in various different EMS settings as proposed in this funding application.

Also given the lack of road safety awareness among the general public, we aim to improve road safety knowledge by using a mobile app for the general public via social media, especially the younger population and integrate first aid training making use of the prime minister's CPR training initiative for schools. 

Paramedics will use the app along with their standard protocols. It is challenging for EMS staff to make use of technology in time-sensitive critical patient care situations especially with limited time to collect and transmit data on route to ER department. Our focus will be on protocols and procedures that would allow for integration of mobile app or the PDA into the workflow of RTA response of the ambulances and subsequent emergency hospital care. After getting consent from EMS services, all volunteers involved in the testing will be asked to complete a baseline and periodic testing questionnaires online. Specific to baseline survey, EMS staff will be asked to fill unprompted and prompted recall information. The online survey will be conducted 6 monthly. Specific to end-line survey, participants will also be asked to grade their experiences related to their engagement with RTA app as defined in the methodology section. 

Quantitative data will be collected throughout the duration of the study to assess frequency of use, time of use, and technical performance at major cities. This will include errors in mobile application or PDA device, data transmission, server and time-stamps for the collection of each data point such as start time for creating a new record, for transmitting a record, and for completion of a record event. 

To study how EMS/ER personnel can operate more efficiently in the future with this application at various sites in different provinces. Selected paramedics and ER staff that use the app or PDA will be invited to participate in a qualitative evaluation which helps assess ambulance services and user perspectives on the value of mobile app for improving EMS communications across all provinces. 

Qualitative data will be collected through a series of group interviews with local personnel who have used the system at least once during the study by the local research team in selected sites. Participants will be asked questions in order to understand their perceptions about the utilization, usability, perceived value and challenges of the system in EMS communication processes and decision-making across Pakistan.

All the academic institutions involved in this proposal have a respectful and caring community of scholars from multidisciplinary fields across the country that understand that diversity is key for this project’s success which starts with Information Technology and Telecom (Development of Mobile App), crosses to Urban Planning (Implementation and Testing in major Cities) and ends with Public Health Surveillance and Epidemiology (Data analysis and integration of App with awareness programs) and goes further. 

The PI is a public health researcher while the Co-PI is from the Department of Computer Science and the diversity in the leadership team helps to look for diverse solutions to the challenge and make more equitable and inclusive decisions during the solution and empowers everyone to learn and do their best at their institutions.

The partners are situated in major cities of all the provinces with affiliate institutes in different cities such as DUHS and SZABIST in Sindh, UHS in Punjab and KMU in KPK, and we appreciate that fact that we are able to involve and reflect the various communities we serve through partnership and open innovation. Having them all aboard makes them ideally suited to manage data collection and ensure accurate records keeping and supervision of the city sites based on their strong public health experiences and key positions in the community focused on shared values of excellence, community, equity, belonging, openness, integrity, and mutual respect.

The researchers have rich experience in artificial intelligence, software development, machine learning, hospital administration and management, epidemiology and public health surveillance which helps us design our policies, practices, and resources with the goal of providing people of all backgrounds a genuine opportunity to thrive. We have a common interest in creating an environment in which everyone feels valued and respected. Here we are developing a public health surveillance system using mobile app for rapid response to emergency and road safety/injury prevention for reducing injury severity.

1- Serving all subjects in an emergency by cross financing

In our solution, Ambulance services can be needed by anybody of any socioeconomic group in case of an emergency. These vehicles are either from public sector (free) or private sector not for profit who provide care at no cost for economically challenged people by generating revenue from people who can afford these services or by donations from various donor agencies to these ambulance services. 

2- Social And Customer Value : 

Ambulance services are not only about moving patient from one place to another but requires comfort and care according to the situation of the emergency. Looking at the future of EMS, getting patients to the appropriate place of care can become a key financial driver to sustaining and running private EMS services. Thus in non emergency situations the patients will request for the most comfortable and well equipped vehicle with well trained staff in place of having no choice during a crisis. 

3- Universal Health Coverage
Improved pre-hospital care at the primary level will reduce the mortality and morbidity burden associated with managing an emergency such as a RTA. This saves extended hospital stay and reduced financial burden to the victim and his family. The funding which is saved by the government can be diverted to be spent on primary health care reinforcing it further. This shift of resources will ultimately lead to universal health coverage.

4 - Impact Measures

Thus, digital technology can not only play an important role of delivering quality patient care within time but evaluating the performance of these EMS services across the country for quality of care and delays to help reduce the national burden on healthcare. 

Funding is needed for setting up the above mentioned infrastructure and once this is in place the information to the ambulance call centers will immediately forward messages to designated ambulances via pager and/or phone. The transmitted data will also identify whether a BLS or ALS ambulance is needed. Further, the smart phone web application combines location tracking services such as GPS with CCTV where available for store in cloud server, other visualization tools on social media and mobile services technologies will capture incident reports/records to be combined in list, map and detailed information via a user-friendly interface across the nation. 

Overall supervision will be by our academic and research collaborators who have agreed to be part of this consortium and will help in faculty capacity building of less research intensive partners. Our collaborators especially those in EMS organizations will help to develop an awareness program for the public via social media app. Feedback from various sectors regarding efficacy of the RTA app would be highly appreciated to update the app accordingly for sustainability.

After three years we expect that the general public will understand the utility of this mobile app and this related technology will be sustained by long term marketing ads on the app especially related to motor and transportation industry as well as using social media to educate the public as done by other business ventures using mobile apps, and also to be incorporated by the government agencies on their websites such as road safety and motorway departments.

HEC NRPU grant has been awarded recently to develop and pilot test the mobile app in Karachi, the largest city of the country.

Details of Grant:  Ref No. 20-14460/NRPU/R&D/HEC/2021 2021 approved on Date: 01.03.22 to Dr. Muhammad Zafar Iqbal Hydrie, Professor, School of Public Health, Dow University of Health Sciences, Karachi

Reference research project No 14460 entitled “Use of Digital Technology for improving Emergency Medical Services to develop mobile apps for
Road Awareness and early response to Road Traffic Accidents” having total cost of nearly Rs. 5,000,000/- and project duration of 36 months, submitted for funding by Dr. Muhammad Zafar Iqbal Hydrie, Dow University of Health Sciences, Karachi, (the Principal Investigator).