American College of Surgeons American College of Surgeons view on the view on the

California Trauma SystemCalifornia Trauma System

James W. Davis MD, FACSJames W. Davis MD, FACS

Professor of Clinical SurgeryProfessor of Clinical Surgery

UCSF/FresnoUCSF/Fresno

The ACS View of California The ACS View of California Trauma SystemTrauma System

A few disclaimers….A few disclaimers….

Conference call withConference call with– John Fildes MD, COT ChairJohn Fildes MD, COT Chair– Wayne Meredith MD, director ACS Trauma Wayne Meredith MD, director ACS Trauma

programsprograms– Mike Rotondo MD, Chair Systems CommitteeMike Rotondo MD, Chair Systems Committee

Sent powerpoint presentations (shamelessly Sent powerpoint presentations (shamelessly borrowed)borrowed)

Some more disclaimers….Some more disclaimers….

There are There are realreal ACS ACS COT experts presentCOT experts present

Past COT ChairsPast COT Chairs– A. Brent Eastman MDA. Brent Eastman MD– David B. Hoyt MD David B. Hoyt MD

COT Vice ChairCOT Vice Chair– Margaret M. Knudson Margaret M. Knudson

MDMD

Last year’s speakerLast year’s speaker– Robert C. Mackersie MDRobert C. Mackersie MD

Trauma Systems Development: Trauma Systems Development: An ACS PerspectiveAn ACS PerspectiveTrauma Systems Development: Trauma Systems Development: An ACS PerspectiveAn ACS Perspective

Robert C. Mackersie, M.D., Robert C. Mackersie, M.D., FACSFACS

Professor of Surgery, UCSFProfessor of Surgery, UCSF

Director, Trauma Services, Director, Trauma Services, SFGHSFGH

Past Chair, ACS-COT Trauma Past Chair, ACS-COT Trauma Systems Planning & Systems Planning & EvaluationEvaluation

Robert C. Mackersie, M.D., Robert C. Mackersie, M.D., FACSFACS

Professor of Surgery, UCSFProfessor of Surgery, UCSF

Director, Trauma Services, Director, Trauma Services, SFGHSFGH

Past Chair, ACS-COT Trauma Past Chair, ACS-COT Trauma Systems Planning & Systems Planning & EvaluationEvaluation

California Trauma System Summit - 2008California Trauma System Summit - 2008California Trauma System Summit - 2008California Trauma System Summit - 2008

ACS ViewACS View

Why develop trauma systems? Why develop trauma systems?

Trauma Systems save livesTrauma Systems save lives– San Diego: decreased preventable deaths from San Diego: decreased preventable deaths from

14% to 3%14% to 3%J Trauma. 1986 Sep;26(9):812-20J Trauma. 1986 Sep;26(9):812-20..

– Oregon: 18% reduction in mortalityOregon: 18% reduction in mortalityJ Trauma 1998; 44(4):609-16.J Trauma 1998; 44(4):609-16.

– Florida: 15% reduction in mortalityFlorida: 15% reduction in mortalityJ Trauma 2006; 60(2): 371-78.J Trauma 2006; 60(2): 371-78.

Mortality Reduction: Mortality Reduction: 25% Lower in TC25% Lower in TC

0

5

10

15

InHospital

30 d 90 d 365 dTCs

NTCs

NEJM 2006;354:366-78

Trauma System DevelopmentTrauma System DevelopmentOverall survival: (Nathens – 2000)Overall survival: (Nathens – 2000)– improvedimproved

MVC Survival: (Nathens – 2000)MVC Survival: (Nathens – 2000)– improvedimproved

Geriatric Survival: (Mann – 2001)Geriatric Survival: (Mann – 2001)– improved improved

Remote Rural Survival: (Mann – 2001)Remote Rural Survival: (Mann – 2001)– ImprovedImproved

Process of care (Olson – 2001)Process of care (Olson – 2001)– improvedimproved

… only a sample of the studies …

Disparities in Access Disparities in Access by Ruralityby Rurality

% of Population Living Within 45 minutes of a

I/II Trauma Center

Urban 89%

Suburban 73%

Rural 8%

Branas, MacKenzie et al, JAMA, 2005

If there is one thing we have, it’s rural…..

What do we do for the rurally What do we do for the rurally injured patient?injured patient?

We cannot just We cannot just shoot ‘emshoot ‘em

We need a We need a REAL state-REAL state-wide trauma wide trauma systemsystem

ACS SystemsACS Systems

Assessment:Assessment: regular and regular and systematic collection and systematic collection and analysis of data to analysis of data to determine status and determine status and need for interventionneed for interventionPolicy Development: Policy Development: establish comprehensive establish comprehensive policies to improve healthpolicies to improve healthAssurance:Assurance: goals to goals to improve the public’s improve the public’s health by providing health by providing regulated servicesregulated services

““ACS Perspective”ACS Perspective”

ACS Regional Trauma Systems: Optimal ACS Regional Trauma Systems: Optimal Elements, Integration and AssessmentElements, Integration and Assessment– Copyright 2008, ACSCopyright 2008, ACS

State of California State Trauma System State of California State Trauma System Implementation: A Discussion DraftImplementation: A Discussion Draft– March 6, 2008March 6, 2008

Standards (optimal elements), and State Standards (optimal elements), and State assessments placed in tables assessments placed in tables – Benchmark Indicator Scores (BIS)Benchmark Indicator Scores (BIS)

System AssessmentSystem AssessmentACS California

Injury Epidemiology Thorough description of epidemiology of injury

Score: 3-5, not statewide data, not linked

Trauma Management Information System

Established trauma MIS Score: 1 - NO

Resource Assessment Assessment completed and updated

Score: 1-3; gap analysis and preventability

Emergency Preparedness Assessment

Assessment completed including Coordination

Score: 1-4 no gap analysis

Cost/Benefit and Societal Investment

Assesses and monitors values to constituents

Score: 1-2 No data available to document

Policy DevelopmentPolicy DevelopmentACS California

Statutory Authority/Administrative Rules

Statutory Authority & Administrative rules

Score: 3-4, BUT legislative authority for all components – lacking

System Leadership Process used to establish, maintain, improve system

Score: 1-5, No clearly defined structure for system decision making process, no goals or objectives

Statewide Trauma System, Plan

Comprehensive written system plan

Score: 2-3, no statewide plan, no evidence to demonstrate an integrated disaster and trauma system

Financial & Infrastructure related resources

Sufficient resources exist, financial and infrastructure

Score: 1-3, no method of assessing resources, no commitment of funds for services, no resources for mass casualty

Policy DevelopmentPolicy DevelopmentACS California

System Performance Data

Data used to evaluate performance and develop policy

Score: 1-4, varying databases, no reporting structure, no system performance standards, no trauma MIS

Performance Reports and Reviews

System leaders review system performance reports

Score: 1-2, no trauma data reports, statewide TAC does not review data reports

Inform/Educate Partnerships

Lead agency informs and educates State, fosters collaboration

Score: 1-3, no public information & education plan

Public Health Emergency Preparedness Links

Trauma, public health and emergency preparedness are linked

Score: 2-3, little surveillance shared with trauma and program linkage is occurring

System AssuranceSystem Assurance

ACS California

Trauma MIS & Outcomes

Trauma MIS used to facilitate assessment & assurance of system performance

Score: 2-3, TC’s have registry, but no state-wide trauma registry

EMS System Support System supported by EMS, trauma, EMS, public health integrated

Score: 2-5; differences in triage criteria, EMS oversight local, no system wide procedure for transfers

Role for all Acute Care Facilities

All acute care facilities integrated into network that meets standards & provides optimal care for all injured patients

Score: 1-4; no plan that outlines roles and responsibilities of all hospitals, no system to review transfers

System AssuranceSystem AssuranceACS California

Analytic Monitoring Tools Agency uses tools to monitor performance

Score: 2-5, annual report, databases accessed only by owners

Integration of Trauma Plan Trauma plan integrated with mass casualty plan

Score: 4-5, plans for integration, drills

Outreach and Prevention Trauma system demonstrates prevention & outreach activities

Score: 2-3, prevention & outreach occurring, not well coordinated

Continuous Trauma Care Improvement

Each hospital must improve care as measured by outcomes

Score 2; mechanism for review, not standardized, no state registry

Rehabilitation Availability Adequate rehabilitation facilities have been integrated into the system

Score: 1; no written standards, no requirement for rehab services to contribute outcomes data

System AssuranceSystem Assurance

ACS California

Financial & QI linkage Financial aspects integrated into quality improvement

Score: 1; no cost data collected, no cost recovery data, no outside financial data

Competent Workforce Lead authority assures a competent workforce

Score: 1-4; lack of standards for nursing and physicians*

Enforce Law, Rules Regulations

Lead authority protects public welfare by enforcing laws, rules & regulations as they pertain to trauma

Score: 2-5; accreditation processes encouraged, not acknowledged

AnalysisAnalysis

Progress Progress has been and is being madehas been and is being made– Registry:Registry: Data dictionary will be approved Data dictionary will be approved

9/23 and data can be submitted as of 11/1 – 9/23 and data can be submitted as of 11/1 – gets to a state-wide registrygets to a state-wide registry

– Authority and rulesAuthority and rules; within statute, language ; within statute, language exists that allows for regulation to be exists that allows for regulation to be developed for trauma systemsdeveloped for trauma systems

ChallengesChallengesDevelopment of Trauma System RulesDevelopment of Trauma System Rules– EMS authorityEMS authority– State wide Trauma Advisory CommitteeState wide Trauma Advisory Committee– Local EMS agenciesLocal EMS agencies

Continuous Trauma Care ImprovementContinuous Trauma Care Improvement– State wide Trauma Advisory CommitteeState wide Trauma Advisory Committee

FundingFunding– County-Federal PartnershipCounty-Federal Partnership

Alameda and LA counties Alameda and LA counties

ACS PerspectiveACS Perspective““San Diego was the San Diego was the Mesopotamia Mesopotamia of of trauma system development”trauma system development”

California could and should be a leader in California could and should be a leader in State-wide trauma systems. State-wide trauma systems.

All the elements are in place for success.All the elements are in place for success.

California has the physician leadership in California has the physician leadership in trauma systems that no one else has. trauma systems that no one else has.

The challenge is here, we can & will meet The challenge is here, we can & will meet it……it……