Northeast Regional Trauma Council

General Membership Meeting Stormont Vail Healthcare Pozez Education Center

Topeka April 11, 2011

Cal to order and Welcome Dr. James Longabaugh, vice chair, called the 2011 NEKRTC General Membership Meeting to order in the absence of Chairman Dr. Michael Moncure. Dr. Longabaugh “thanked” Stormont Vail Hospital for hosting the meeting. He asked all members to introduce themselves and the organization that they represent. Dr. Longabaugh reminded the members to complete their evaluations throughout the day, sign the sign-in roster, and complete their statement of attendance for continuing education credits. Trauma System Development Rosanne Rutkowski, Kansas Trauma Program Director, provided the presentation. Her presentation provided information on the program’s achievements, current projects, and future goals. Click here to view her presentation. Interpreting Trauma Registry Data Dee Vernberg, Trauma Program Epidemiologist, provided findings from trauma registry data for the NE region. Her presentation described characteristics of the NE Trauma Region and outlined the two primary ways trauma registry can be used to enhance system development (primary prevention and Performance Improvement). Legislative Update Senator Vicki Schmidt, District 20th District, gave an update on the 2011 legislative session including information on SB139, SB216, mega health bill, and other bills of interest to the regional trauma council. Community Health Assessment: The Things Your Hospital Needs to Know About the Process Sara Roberts, Kansas Rural Health Program Director, provided the presentation. Her presentation included information regarding the Community Health Assessment and components of the assessment that hospitals need to be aware of. Click here to view her presentation and handouts. Making a Difference: Public Health’s Role in Injury Prevention Dr. Won Choi, KU-MPH Program Executive Director, provided the presentation. His presentation included injury statistics and suggested possible injury prevention initiatives for the region. Click here to view his presentation.

Lunch provided and hosted by the NEKRTC Executive Committee CDC Field Triage Guidelines-Lessons Learned Dr. Robert Dodson, SE CDC Field Triage Guidelines Pilot Project Team Leader and SEKRTC Chairman, provided the presentation. His presentation included information on the SE field triage guidelines pilot project including implementation strategies. Click here to view his presentation.

Panel Discussion: Using the Trauma Registry Benchmark Data Report Facilitator-Liz Carlton

o Panel- Janne Adams Denton-Community Health Systems, Onaga o Panel- Terri Woodson, Lawrence Memorial Hospital o Panel- Tessa White, Hiawatha Community Hospital o Panel- Amber Hatfield, Hiawatha Community Hospital o Panel- Angelia Pebley, St. John’s Hospital, Leavenworth

Liz Carlton facilitated the data report panel discussion. Click here to view her panel presentation power point. The participants outlined 1) how findings in the data report helped them to enhance their trauma registries (e.g. to develop better methods for identifying trauma patients – ED Log), 2) they gave suggestions how to properly interpret findings from the data report for smaller institutions (e.g. missing ISS scores may not indicate missing data but may indicate a diagnosis of possible injury which can not be coded as an ISS score) and 3) Who should receive the data report in facilities (e.g. CEO, CNO, DON, Risk/Quality Managers, ED Manager). The panel comments stimulated a group discussion on how the region can communicate more effectively to enhance data quality (e.g. EMS providers who perform a procedure (e.g. intubation or chest tube placement) on a patient in the ED should communicate with ED staff so they can document in the hospital record that this procedure was performed before inter-facility transfer. Business Meeting Elections

Dr. Longabaugh referred all voting members to the voting ballot included in the meeting materials packet.

Dr. Longabaugh introduced the candidates on the ballot: o EMS

JJ Cashier, Jackson County EMS Natalie Hartig, Johnson County Med ACT

Dr. Longabaugh asked for nominations from the floor EMS representatives. No nominations were received. o Nurse

Julie Unruh, St. Francis Health Center

Dr. Longabaugh asked for nominations from the floor for Nurse representatives. No nominations were made. o Administrator

Liz Carlton, University of Kansas Hospital

Dr. Longabaugh asked for nominations from the floor for Administrator representatives. No nominations were made. o Health Department

Jon Anderson, NEK Multi Health Department

Dr. Longabaugh asked for nominations from the floor for Health Department representatives. No nominations were made.

o Physician No representative on ballot

Dr. Longabaugh asked for nominations from the floor for Physician representatives. Dr. Don Fishman, Overland Park Regional Medical Center, was nominated for Physician representative. With nominations complete, Dr. Longabaugh asked the voting members to complete their ballot. Election results: EMS Representative Natalie Hartig, Johnson County Med Act Nurse Representative Julie Unruh, St. Francis Health Center Administrator Representative Liz Carlton, University of Kansas Medical

Center Health Department Representative Jon Anderson, NEK Multi Health Departments

Physician Representative Dr. Don Fishman, Overland Park Regional

Medical Center Subcommittee Updates Education Subcommittee Liz Carlton provided the education subcommittee report.

o PHTLS Atchison Hospital EMS

August 28 & 29, 2010 11 participants

Miami County EMS September 24 & 25, 2010 19 participants

Seneca EMS Scheduled for April 2011

o TNCC

Horton Community Hospital October 12 & 13, 2010 16 participants

Sabetha Community Hospitals 12 scholarships provided

Miami County Hospital

July 15 & 16, 2010 8 participants

RTTDC

Hiawatha Community Hospital

o May 14, 2010 o 6 participants

Onaga Community Hospital o December 14, 2010

Atchison Hospital o July 27, 2010 o 14 participants

Other sponsored education

ATLS o Stormont Vail

July 14, 2010 17 participants

ATLS Instructor Scholarships o 2 provided for KU February class

EMD Scholarships

o 4 Scholarships award As a reminder, Liz announced that KRHOP funding applications are due April 15th for PHTLS, TNCC, RTTDC, and ATLS scholarships. Injury Prevention Subcommittee Liz Carlton provided the injury prevention subcommittee report.

The regional trauma council provided funding to the Kansas Department of Transportation’s (KDOT) Seatbelts Are For Everyone (SAFE) Program that is now in 107 schools across the state. Fall prevention: May is Trauma Awareness Month. The focus is on fall prevention. A kit will be emailed this week.

We are also looking at other fall prevention opportunities. Performance Improvement Subcommittee Scott Harrison provided the performance improvement subcommittee report.

The NE RTC Executive Committee held a performance improvement workshop in October at Stormont Vail. We had over 50 participants from across the NE region. Evaluations were good and would like something developed geared more towards the hospitals that are considering level IV designation. Regional Benchmark Data Reports: The executive committee is beginning to review the benchmark data reports for enhancing system development.

Bylaws Revision (Action) The proposed bylaws revision included adding Advisory Committee on Trauma (ACT) representative language on page 5 of the bylaws. After review and discussion of the bylaws Scott Harrison made the motion to approve the bylaws as presented. Lois Towster seconded the motion. The motion passed.

Regional Trauma Plan (Action)

The NE regional trauma plan was updated and edited. The regional trauma plan format has been changed to work plan format. The regional budget has also been edited to mirror the regional trauma plan and will be used to accomplish goals and objectives of the plan. After review, Scott Harrison made the motion to approve the regional trauma plan as presented. Lois Towster seconded the motion. The motion passed.

In closing

The NEKRTC provided two registrations, by raffle, to the Midwest Trauma Society Meeting in May. Winners of the raffle were Donna Zinke, Nemaha County Community Hospital, and Matt Laing, Miami County EMS.

Dr. Longabaugh reminded the general membership meeting participants to complete evaluations and statement of attendance and place on registration table.

Dr. Longabaugh thanked Stormont Vail Hospital for hosting the meeting and thanked everyone for attending.

Adjournment Meeting adjourned at 3:00pm. Follow up note: There were 39 members in attendance.

Kansas Trauma System 2011

R R k ki RN MPHRosanne Rutkowski, RN, MPH

Kansas Trauma Program

Welcome

• Objectives:j– Provide update on progress to date

– What we’ve accomplishedp

– What lies ahead

ACS Triage Inclusive Trauma Systemg y

Mackersie, Prehosp Emergency Care ’06

How to Make a Difference

• Participate with your regional trauma p y gcouncil

• Education of EMS, RN’s, MD’s &Education of EMS, RN s, MD s & Registrars

• Contact your legislator• Contact your legislator

• Encourage participation

• Spread the news & Share the wealth!

What are the Qualities of a GoodWhat are the Qualities of a GoodTrauma System?Trauma System?yy

• Network of hospitals with the commitment and the resources to care for trauma system patients

• Organized plan to route critical patients to the right hospital that is ready to care f thfor them

• Constant monitoring of the system to correct problems impro e the s stemcorrect problems, improve the system, and validate the quality of care providedprovided

How does the System Save Lives?How does the System Save Lives?

• It correctly identifies the patients who need ttrauma care

• Anticipates the resources needed to treat the patientspatients

• Locates the available needed resources• Routes the patient “right” the first time toRoutes the patient right the first time to

reduce time to appropriate care• Arranges interfacility transfers if needed to g y

reduce time to appropriate care• Improves care by the QI process

Who is a “Trauma System” Patient?Who is a “Trauma System” Patient?

• A “trauma” patient is any patient who is injured• Most injuries are minor and should be treated at a• Most injuries are minor and should be treated at a

local community hospital• Less than 10% of patients with injuries need to go to

a trauma center These are Trauma System patientsa trauma center. These are Trauma System patients. • A “Trauma System” patient has life-threatening

injuries that require rapid, specialized care. Examples are:Examples are:

• Injured patients with signs of shock• Injured patients with airway problems• Head or spinal injuriesHead or spinal injuries• Multiple long bone fractures• Ejection from vehicle• Major burns or smaller burns with other injuriesj j

This is an Trauma Patient but not a This is an Trauma Patient but not a Trauma System PatientTrauma System Patientyy

Fracture-Dislocation of the Ankle

This is a Trauma Patient but not a This is a Trauma Patient but not a Trauma System PatientTrauma System Patientyy

Open Fracture-Dislocationof the Ankle

This is a Trauma System PatientThis is a Trauma System Patient

Rural TraumaRural TraumaRural TraumaRural Trauma

• Challenges in rural gtrauma care– ALS often not available.

Response Times 23– Response Times 23 Min+

– Most hospitals do not have the resourceshave the resources (surgical specialties) to provide definitive trauma caretrauma care

– Arranging transfer to definitive care often takes hourstakes hours

SB 139

• lxlxlxlxl

Understanding the legis

xxx

“Being a trauma center is a journey notBeing a trauma center is a journey, not a destination. But…

It’s a journey our patients will be grateful that we made”. Trauma Director

“Never doubt that a small group of people of thoughtful committed citizens can change the world. Indeed, it’s the only thing that ever has.”

Margaret Mead

COMMUNITY HEALTHASSESSMENTS:

Sara Roberts, MPH Director of Rural HealthBureau of Local and Rural Health

Assessing Community Needs Community Benefit Assessment Conducting Environmental Scans

Various Approaches by Organizations: Community Health and Programs Services

(CHAPS) Assessment Mobilizing for Action through Planning and

Partnerships (MAPP) Rural Health Works Community Engagement Catholic Health Assn - Healthy Community

Institute Model

COMMUNITY HEALTH ASSESSMENTS‘JARGON’ AND ‘APPROACHES’

COMMUNITY HEALTH ASSESSMENTS

The foundation for improving and promoting the health of community members.

It is a "systematic collection, assembly, analysis, and dissemination of information about the health of the community.

A community assessment team looks at community assets, strengths, resources, and needs.

Resource Link: http://www.healthycarolinians.org/assessment/guidebook.aspx

We Know: Actions Should be Responsive to Local

Community Needs

Data Should Drive Decisions Made

Assessment is one-part of a Continuous Process - Community Improvement Planning, Quality Improvement

The Collective Effort is Stronger than Individual Effort

WHY ARE COMMUNITY HEALTHASSESSMENTS IMPORTANT?

CHARITABLE HOSPITALS MUST: Complete Community Needs Assessment Meet Financial Assistance Policy

Requirements Adhere to Limitations on Charges Follow Billing and Collection Practices

The Patient Protection and Affordable Care Act creates new IRS Code Section 501(r) which imposes 4 new requirements on tax-exempt hospitals.

HOSPITAL’S ROLE –

Hospitals must adopt and implement a strategy to meet the community health needs.

Assessment must input from persons that represent the “broad” interest of the community serve and must include public health experts.

Hospitals must report how the organization is strategically addressing the needs identified.

Requirement applies to tax years that start after March 23, 2012.

PATIENT PROTECTION ANDAFFORDABLE CARE ACT REQUIREMENTS

Resource Link: http://www.ruralcenter.org/sites/default/files/PPACA%20Tax%20Exempt%20Hospital%20Status%20Requirements_0.pdf

Public Health Accreditation Requirements Conduct community assessments focused on

population health status and public health issues

Engage with the community to identify and address health problems

Develop public health policies and plans

Promote strategies to improve access to healthcare services

LOCAL PUBLIC HEALTH’S ROLE -

Resource Link: http://www.phaboard.org/assets/documents/PHABLocalJuly2009-finaleditforbeta.pdf

Resolution Signed between the Kansas Hospital Association (KHA) and the Kansas Association of Local Health Departments (KALHD)

KHA Community Needs Assessment Workgroup Workgroup Charge: Research, review, and recommend

options and strategies that will assist providers in meeting the community needs requirements

Development of Supporting Information Systems Dashboard-style reports to look at 50-60 core data

measures Resources to look for evidence-based practices

PUBLIC HEALTH AND HOSPITALCOLLABORATION

Community Health Assessments Health

System Thinking

WHY ARE COMMUNITY HEALTHASSESSMENTS IMPORTANT?

Why? Trauma is Key in Local Health System Invested in improving the quality of health of the

community Essential piece in to the community’s local health

system

Potential Benefits of Involvement: Network Opportunities with other health providers

and community members Increased Community Awareness of the Trauma

system as a Key Resource Community Support for Trauma systems

development and injury intervention initiatives

BEING INVOLVED IN COMMUNITYHEALTH ASSESSMENTS

RTC DISCUSSION AND FEEDBACK

Proposed Local Standards and MeasuresAdopted by the PHAB Board of Directors

July 16, 2009 For PHAB Beta Test

Overarching Guidance The Exploring Accreditation Report (Winter 2006-2007) is the foundational document for the development of a voluntary national accreditation program and its standards. The draft standards were developed by a nation-wide workgroup through review and use of 15 sets of state and national standards, including NACCHO’s Operational Definition (including metrics), NPHPSP state and local, Project Public Health Ready, and results of ASTHO’s State Public Health Survey. The first version of Proposed PHAB Standards was reviewed through an alpha test with two state agencies and six local health departments. The revised proposed standards were reviewed through an extensive, formal vetting process that resulted in more than 3,700 comments from all parts of public health throughout the US. This July 10, 2009 version reflects revisions to the Standards to address these comments.

In addition to the standards and related measures, the documentation guidance provides detail for sites and site surveyors about how the measures will be reviewed.

The following overview provides a framework for reviewing the Proposed PHAB standards and measures. � Structural Taxonomy

In general, a reference to “the standards” includes reference to domains, standards, measures and guidance for documentation. The proposed standards are divided into two parts. Part A includes standards for administrative capacity and governance. Part A uses the following taxonomy: o Standard o Measure o State, Local or Both

A1A1.1A1.1 S (state) or L (local) or B (both)

Part B uses the structure of the Ten Essential Services and Operational Definition. Part B uses the following taxonomy: o Domain o Standard

o Measure o State, Local or

Both

11.1 (Note that each standard has a short form “title” followed by a full standard

statement.) 1.1.1 1.1.1 S (state) or L (local) or B (both)

The majority of the standards and measures are the same for both state and local departments. Where the standard or measure is either local or state, the measures often address similar topics but have

Proposed Local Domains, Standards and Measures Review Draft – July 2009 Page 1 of 51

slight differences in wording. For instance, the standard and some measures for health improvement plans are specific to local or state due to the distinction of community health improvement plans (CHIPs) at the local level and state health improvement plans (SHIPs) at the state level.

� Numbers of Standards and Measures o There are 11 Domains—the administrative capacity and governance domain in Part A and the ten

domains in Part B. o There are 30 Proposed Standards applicable to state public health departments and 30 Proposed

Standards applicable to local public health departments. o There are 111 proposed measures applicable to state health departments. o There are 102 proposed measures applicable to local health departments.

� The Standards and measures address a broad range of governmental public health activities, including environmental public health, human resources, and IT even if these functions are conducted by another agency. Please see the Structural Arrangements, Issue 1 below for more details.

� Documentation GuidanceThere are many methods for producing the documents required or suggested in the Guidance. Some may be produced by local health department staff; others by state health department staff for the use by local health departments; others by partnerships, regional collaborations and/or the use of contracted services. The focus of documentation is that the material exists and is in use in the agency being reviewed, not who originated the material. All documentation must be in effect at the time of the PHAB accreditation survey. No draft documents will be reviewed for scoring. Similarly, documents must be dated in order for reviewers to evaluate compliance with timeframes. Documentation need not be presented in a single document; several documents may support demonstration of a single measure. Conversely, a single document may be relevant for more than one measure. Documents may be electronic, web-based and/or hard copy. The documentation guidance for the measures can contain two types of information: o “Required Documentation” is a description of the topics and issues that the documentation must

contain to demonstrate the measure, and o “Examples of Documentation” describes some examples of the types of documentation that

could be presented. These examples are not inclusive of every type of documentation that a health department could present. Health departments are encouraged to present valid documentation in the formats used in regular agency operations.

o Many types of documentation can be used to demonstrate performance: � Examples of documentation that describe policies and processes: policies, procedures,

protocols, standing operating procedures, ERP, manuals, flowcharts, logic models or other documentation

� Examples of documentation for reporting activities, data, decisions: health data summaries, survey data summaries, data analysis, audit results, meeting agendas, committee minutes and packets, after-action evaluations, CE tracking reports, work plans, financial reports, quality improvement reports or other documentation

� Examples of materials to show distribution and other activities: email, memoranda, letters, dated distribution lists, phone books, health alerts, Fax, case files, logs, attendance logs, position descriptions, performance evaluations, brochures, flyers, website screen prints, news releases, newsletters, posters, contracts or other documentation

Note: The Documentation Guidance is still in development and will be expanded based on input during the Beta Test.

Proposed Local Domains, Standards and Measures Review Draft – July 2009 Page 2 of 51

Summary of Standards Part A: Administrative Capacity and Governance

Provide Infrastructure for Public Health Services Standard A1 B: Develop and maintain an operational infrastructure to support the performance of public health functions.

Provide Financial Management SystemsStandard A2 B: Establish effective financial management systems.

Define Public Health Authority Standard A3 B: Maintain current operational definitions and statements of the public health roles and responsibilities of specific authorities.

Provide Orientation / Information for the Governing Entity Standard A4 B: Provide orientation and regular information to members of the governing entity regarding their responsibilities and those of the public health agency.

Part B Domain 1: Conduct and disseminate assessments focused on population

health status and public health issues facing the community

Collect and Maintain Population Health Data Standard 1.1 B: Collect and maintain reliable, comparable, and valid data that provide information on conditions of public health importance and on the health status of the population.

Analyze Public Health Data Standard 1.2 B: Analyze public health data to identify health problems, environmental public health hazards, and social and economic risks that affect the public’s health.

Use Data for Public Health Action Standard 1.3 B: Provide and use the results of health data analysis to develop recommendations regarding public health policy, processes, programs or interventions.

Domain 2: Investigate health problems and environmental public health hazards to protect the community

Investigate Health Problems and Environmental Public Health Hazards Standard 2.1 B: Conduct timely investigations of health problems and environmental public health hazards in coordination with other governmental agencies and key stakeholders.

Contain/Mitigate Health Problems and Environmental Public Health Hazards Standard 2.2 B: Contain/mitigate health problems and environmental public health hazards in coordination with other governmental agencies and key stakeholders Maintain Provision for Epidemiological, Laboratory, and Support Response Capacity Standard 2.3 B: Maintain access to laboratory and epidemiological/environmental public health expertise and capacity to investigate and contain/mitigate public health problems and environmental public health hazards.

Proposed Local Domains, Standards and Measures Final Draft - July-09 Page 5 of 51

Maintain Policies for Communication Standard 2.4 B: Maintain a plan with policies and procedures required for urgent and non-urgent communications.

Domain 3: Inform and educate about public health issues and functions

Provide Prevention and Wellness Policies, Programs, Processes, and Interventions Standard 3.1 B: Provide health education and health promotion policies, programs, processes, and interventions to support prevention and wellness.

Communicate Information on Public Health Issues and Functions Standard 3.2 B: Provide information on public health issues and functions through multiple methods to a variety of audiences.

Domain 4: Engage with the community to identify and address health problems

Engage the Public Health System and the Community in Identifying and Addressing Health ProblemsStandard 4.1 B: Engage the public health system and the community in identifying and addressing health problems through an ongoing, collaborative process. Engage the Community to Promote Policies to Improve the Public’s Health Standard 4.2 B: Promote understanding of and support for policies and strategies that will improve the public’s health.

Domain 5: Develop public health policies and plans

Establish, Promote, and Maintain Public Health Policies Standard 5.1 B: Serve as a primary resource to governing entities and elected officials to establish and maintain public health policies, practices, and capacity based on current science and/or promising practice.

Develop and Implement a Strategic Plan Standard 5.2 B: Develop and implement a health department organizational strategic plan.

Conduct a Community Health Improvement Planning Process Standard 5.3 L: Conduct a comprehensive planning process resulting in a community health improvement plan [CHIP].

Maintain All Hazards/Emergency Response Plan Standard 5.4 B: Maintain All Hazards/Emergency Response Plan (ERP).

Domain 6: Enforce public health laws and regulations

Maintain Up-to-Date Laws Standard 6.1 B: Review existing laws and work with governing entities and elected officials to update as needed.

Proposed Local Domains, Standards and Measures Final Draft - July-09 Page 6 of 51

Educate About Public Health LawsStandard 6.2 B: Educate individuals and organizations on the meaning, purpose, and benefit of public health laws and how to comply.

Conduct Enforcement ActivitiesStandard 6.3 B: Conduct and monitor enforcement activities for which the agency has the authority and coordinate notification of violations among appropriate agencies.

Domain 7: Promote strategies to improve access to healthcare services

Assess Healthcare Capacity and Access to Healthcare Services Standard 7.1 B: Assess healthcare capacity and access to healthcare services.

Implement Strategies to Improve Access to Healthcare Services Standard 7.2 B: Identify and implement strategies to improve access to healthcare services.

Domain 8: Maintain a competent public health workforce

Maintain a Qualified Public Health Workforce Standard 8.1 B: Recruit, hire and retain a qualified and diverse public health workforce.

Maintain a Competent Public Health Workforce Standard 8.2 B: Assess staff competencies and address gaps by enabling organizational and individual training and development opportunities.

Domain 9: Evaluate and continuously improve processes, programs, and interventions

Evaluate the Effectiveness of Public Health Processes, Programs, and Interventions Standard 9.1 B: Evaluate public health processes, programs, and interventions provided by the agency and its contractors.

Implement Quality Improvement Standard 9.2 B: Implement quality improvement of public health processes, programs, and interventions.

Domain 10: Contribute to and apply the evidence base of public health

Identify and Use Evidence-Based and Promising Practices Standard 10.1 B: Identify and use evidence-based and promising practices.

Promote Understanding and Use of Research Standard 10.2 B: Promote understanding and use of the current body of research results, evaluations, and evidence-based practices with appropriate audiences.

Proposed Local Domains, Standards and Measures Final Draft - July-09 Page 7 of 51

National Rural Health Resource Center August 2010 1

PPACA Tax Exempt Hospital Status Requirements: 9007

The Patient Protection and Affordable Care Act: section 9007 (Pub. L. No. 111-148) includes four primary adjustments to the federal income tax exemption requirements for nonprofit hospitals. Nonprofit is defined as an organization exempt from federal income tax under section 501(c) (3) of the Internal Revenue Code. Hospital is defined as an organization that is licensed, registered, or similarly recognized as a hospital. If a hospital organization operates more than one hospital facility, the organization is required to meet the requirements separately with respect to each facility. Under the act, tax-exempt hospitals must take the following actions to avoid penalties:

• Conduct a community health needs assessment at least once every three years that takes into account the broad interests of the community served by the hospital and must include individuals with expertise in public health

o The community health needs assessment must be made widely available to the public.

o An action plan must be developed by the hospital that identifies how the assessment findings are being implemented in a strategic plan.

o If the findings are not being utilized in a strategic plan, documentation must be included as to why they are not being addressed at this time.

o Requirements are met only if the organization has conducted a community health needs assessment in the taxable year or in either of the two taxable years immediately preceding the current taxable year.

� Applicable beginning in taxable years starting after March 23, 2010

� Will need to complete a needs assessment and adopt an implementation plan some time during a period that begins with the start of the first tax year after March 23, 2010 and end of its tax year the begins after March 23, 2012.

• Make financial assistance policies widely available which specifies eligibility criteria for discounted care and how billed amounts are determined for patients (Interpretation: prohibits the use of gross charges)

• Notify patients of financial assistance policies through “reasonable efforts” before initiating various collection actions or reporting accounts to a credit rating agency (“Reasonable efforts” is yet to be defined as of 8/19/10)

National Rural Health Resource Center August 2010 2

• Restrict charges of uninsured, indigent patients to those amounts generally charged to insured patients

This act imposes penalties on hospitals that fail to timely conduct their community health needs assessments which could include penalties of equal to $50,000 and possible lose of the organization’s tax exempt status. Under the act, the Internal Revenue Service must review the exempt status of hospitals every three years. In addition, the act requires the U.S. Department of the Treasury, in consultation with the U.S. Department of Health and Human Services (HHS), to prepare an annual report for the U.S. Congress on charity care, bad debt expenses, certain unreimbursed costs and costs incurred for community benefit activities. In five years, Treasury and HHS must also provide Congress with a report on community benefit-related trends.

For additional information, please review the requirement as laid out in the legislation (see link above) and contact the Technical Assistance and Services Center (TASC), a program of the National Rural Health Resource Center, at tasc@ruralcenter.org or (218) 727-9390.

Public Health’s Role in Injury PreventionPublic Health’s Role in Injury Prevention

Won S. Choi, PhD, MPHAssociate Professor

E ti Di tExecutive DirectorMPH Program

University of Kansas Medical Center

Public Health and Injury Prevention

“ The public health approach to injury prevention is a process that involvesprevention is a process that involves identifying and defining the problem, identifying risk and protective factors,identifying risk and protective factors, developing and testing prevention strategies, and assuring widespreadstrategies, and assuring widespread adoption of effective strategies.”

Source: KDHE, Bureau of Health Promotion, Office of Injury Prevention Program

Motor Vehicle Related Total Costs U SMotor Vehicle Related Total Costs – U.S.

Source: Naumann et al., Traffice Injury Prevention, 2010

Injury-Related Mortality in Kansas2003-2007

• Majority of injury related deaths – unintentional injury

• Motor vehicle crashes – number one cause of unintentional injury deaths (2,314)

• Highest rates of motor-vehicle related injury deaths in l 15 24 d 75+males15-24 years and 75+ yrs.

• Falls ranked 2nd in number of unintentional injury deaths (1,082)( , )

• Overall – rate of injury death in KS is 2 times higher among males vs. females

Source: KDHE, Bureau of Health Promotion, Office of Injury Prevention Program

S CStates with Highest MVC Fatality Rates (16-17 year olds)

• Mississippi

• Wyomingy g

• Alabama, Louisiana

• West Virginia

• South Carolina

Source: MMWR 2010;59(41):1329-1334

S CStates with Lowest MVC Fatality Rates (16-17 year olds)

• District of Columbia

• Massachusetts

• New York

• Rhode Island

• New Jersey

More Statistics related to Teenage Driving

• 16-yr olds are more than 20 times as likely to have a MVC than any other licensed driver

• Adolescents are far less likely to use seat belts than any• Adolescents are far less likely to use seat belts than any other age group

• Adolescents cause disproportionate number of deaths p pamong non-adolescent drivers, passengers, and pedestrians

• Alcohol is involved in nearly 23% of adolescent• Alcohol is involved in nearly 23% of adolescent

(15-20yrs) driver fatalities

• 54% of all teen MV deaths occur on Friday, Saturday54% of all teen MV deaths occur on Friday, Saturday and Sunday. 35% occur between 9pm and 3am.

Source: National Highway Traffic Safety Administration

Major Risk Factors for Teenage MVC

• Lack of Driving Experience (nighttime driving, response time to traffic hazards, ability to integrate speed, control of vehicle etc)of vehicle, etc)

• Risk behavior of teenagers (seat belt use, alcohol and g (drugs, peer pressure, etc)

Di t t d D i i ( ll h t ti t lki )• Distracted Driving (cell phone use – texting, talking)

Source: National Highway Traffic Safety Administration

Falls among the Elderly in the U.S.

How big is the problem?

• One in three adults age 65 and older falls each year.One in three adults age 65 and older falls each year.

• Of those who fall, 20% to 30% suffer moderate to severe injuries that make it hard for them to get around or live independently, and g p yincrease their risk of early death.

• Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.

• In 2009, emergency departments treated 2.2 million nonfatal fall inj ries among older ad lts more than 582 000 of these patients hadinjuries among older adults; more than 582,000 of these patients had to be hospitalized.

Falls among the Elderly in the Kansas

• In 2008, falls led to 8,217 hospital discharges

• Seniors (65 years and older) made up 73% of the fall relatedSeniors (65 years and older) made up 73% of the fall related discharges

• Women made up 66% of all falls related hospital dischargesp p g

• 279 deaths in Kansas in 2008 due to falls

• In 2008, falls had more hospital discharges then motor vehicle, poisonings, burns and drownings combined

Source: KDHE, Bureau of Health Promotion, Office of Injury Prevention Program

How costly are fall related injuries amongHow costly are fall-related injuries among older adults?

•In 2000, the total direct medical costs of all fall injuries for people 65 and older exceeded $19 billion: $0.2 billion for fatal falls, and $19 billion for nonfatal falls.

B 2020 th l di t d i di t t f f ll i j i i t d t h•By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion (in 2007 dollars).

•Among community-dwelling seniors treated for fall injuries, 65% of direct g y g j ,medical costs were for inpatient hospitalizations; 10% each for medical office visits and home health care, 8% for hospital outpatient visits, 7% for emergency room visits, and 1% each for prescription drugs and dental visits. About 78% of these costs were reimbursed by Medicarethese costs were reimbursed by Medicare.

•In a study of people age 72 and older, the average health care cost of a fall injury totaled $19,440, which included hospital, nursing home, emergency room, and home health care, but not doctors’ services.

Type of injury and treatment setting

I 2000 t ti b i i j i (TBI) d i j i t th hi l d f t• In 2000, traumatic brain injuries (TBI) and injuries to the hips, legs, and feet were the most common and costly fatal fall injuries, and accounted for 78% of fatalities and 79% of costs.

• Fractures were both the most common and most costly type of nonfatal injuries. Just over one third of nonfatal injuries were fractures, but they accounted for 61% of costs—or $12 billion.

• Hospitalizations accounted for nearly two thirds of the costs of nonfatal fall injuries, and emergency department treatment accounted for 20%.

• On average, the hospitalization cost for a fall injury is $17,500.

•Hip fractures are the most frequent type of fall-related fractures. The cost of hospitalization for hip fracture averaged about $18 000 Hospitalization costshospitalization for hip fracture averaged about $18,000. Hospitalization costs accounted for 44% of direct medical costs for hip fractures.

Preventing Falls

• Exercising regularly. It’s important that the exercise focuses on increasing leg strength and improving balance.

• Asking a doctor or pharmacist to review medicines—both prescription and over-the counter—to reduce side effects and interactions that may cause dizziness or drowsiness.

• Having a vision check by an eye doctor at least once a year and updating eyeglasses to maximize vision.

• Making home safety improvements by reducing tripping hazards, adding grab bars and railings, and improving lighting.

DEVELOPING ESSENTIAL PARTNERSHIPS

An effective senior falls prevention program typically includes public healthAn effective senior falls prevention program typically includes public health professionals, community service providers and health care professionals.

The role of public health is to:

• Share information on evidence-based best practices for senior falls prevention

• Assist in developing the partnerships needed for successful program implementation

P id t h i l i t h d d t l t• Provide technical assistance when needed to evaluate program implementation or impact

CDC/SERTC Field Triage Pilot Project

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

History of the Decision Scheme

National consensus conference in 1987 resulted in first ACS field triage protocol, the “Triage Decision Scheme”

The Decision Schemeserves as the basis for field triage of trauma patients in most EMS systems in the U.S.

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

History of the Decision Scheme

The Decision Scheme has been revised four times (1990, 1993, 1999, 2006)

In 2005-2006 the Centers for Disease Control and Prevention (CDC), with support from the National Highway Traffic Safety Administration (NHTSA), convened the National Expert Panel on Field Triage

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

National Expert Panel on Field Triage

Membership –National leadership, expertise, and contributions in the realm of injury

prevention and control

Members–EMS Providers and Medical Directors–Emergency Medicine Physicians and

Nurses–Trauma Surgeons–Public Health–Federal Agencies–Automotive Industry

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

National Expert Panel on Field Triage

The role of the Expert Panel is to:–Periodically review the Decision

Scheme–Ensure criteria are consistent with

existing evidence –Ensure criteria are compatible

with advances in technology –Make necessary

recommendations for revision

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Why this Decision Scheme is Unique

Takes into account recent changes in assessment and care of the injured patient in the U.S.

Adds views of a broader range of disciplines and expertise into the process

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Purpose This Decision Scheme was

revised to facilitate more effective triage and better match trauma patients’ conditions with the medical resources best equipped to treat them

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Step 1: 2006 ChangesAdded

–A threshold for respiratory rate (<20 bpm) in infants

Removed–Revised Trauma Score

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Step 2: Anatomic Criteria

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Step 2: 2006 ChangesAdded

–Crushed, degloved, or mangled extremity

Modified– “Open and depressed” changed to

“open or depressed” skull fracture

Removed– Burns moved to Step Four

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Step 3: 2006 Changes Added

–Vehicle telemetry data consistent with high risk of injury

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Step 3: 2006 Changes Modified

– Falls:• Adults: >20 feet

(one story = 10 feet)• Children: >10 feet, or 2–3 times the

child’s height– “High speed auto crash” was

changed to “high-risk auto crash”

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Step 3: 2006 ChangesModified

–Intrusion modified to >12 inches at occupant site or >18 inches at any site

–Auto-pedestrian/struck/auto-bicycle injury changed to “Auto v. pedestrian/bicyclist thrown, run over, or with significant (>20mph) impact”

– Motorcycle crash shortened to “Motorcycle crash >20mph”

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Step 3: 2006 ChangesRemoved

–Rollover crash –Extrication time >20 minutes–Crush depth –Vehicle deformity >20

inches and vehicle speed >40 mph

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Step 4: 2006 ChangesAdded

–Burns (moved from Step Two)

–Time-sensitive extremity injuries

–End stage renal disease requiring hemodialysis

–EMS Provider judgment

P age S ource: American C ustomer S atis faction Index, Oct. 4, 2008 – J an. 31, 2009

Step 4: 2006 ChangesModified

–Age• Older adults: Risk of injury/death increases after age 55• Children: Should be triaged preferentially to pediatric capable

trauma centers

– Pregnancy changed toread “Pregnancy greater than 20 weeks”

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Step 4: 2006 ChangesRemoved

–Cardiac and respiratory disease

–Diabetes Mellitus–Morbid obesity–Immunosuppression–Cirrhosis

SERTC Pilot Project

Small grant from CDC

6 Month Pilot

Why SE Region?

Rural

2 Level III Trauma Centers

Key Strategies

Meet with hospitals

Meet with EMS Council

Follow up when needed

Kickoff

Workshops for EMS and hospitals

3 Locations

17 of 19 EMS agencies

12 of 13 hospitals

EMS Providers

Data collection form

Send it to registrar at receiving hospital

Make recommendations to the project team

Registrars

Complete the data collection form

Send complete data form to Kansas Trauma Program

Hospitals

Support your local EMS agencies

Timeline

started Oct 2010

Ended Mar 2011

Initial Concerns

START Triage

Why change

Bypassing our hospital

EMTALA

EMS Medical Director support

Challenges

Continued concern of bypassing hospital

Support of EMS Medical Directors

Sharing data across state lines

Strategy for Success

All disciplines on project team

Rollout workshops

EMTALA

CMS representative at rollout workshops

Next Steps

Data analysis

Evaluate regional result

Rollout statewide

Using the Trauma RegistryUsing the Trauma Registry Benchmark Data Report p

Facilitator: Liz Carlton, University of Kansas Hospital

Panel:

Janne Adams Denton, Community HealthCare System, Onaga

Elaine Swisher, Lawrence Memorial Hospital

Lavon Harmon, Atchison Hospital

Tessa White & Amber Hatfield, Hiawatha Community Hospital

Sandi Butler, Horton Community Hospital

Angelia Pebley, St. John’s Hospital, Leavenworth

ObjectivesObjectives

• Review of data reportReview of data report• Identifying cases

f C l i d• Importance of Completing data• Focused review on elements: transfer guidelines , TBI, etc

DiscussionDiscussion

• What is it?What is it?• Never seen it before.

h d i b h id h• They send it to me, but I have no idea what to do with it.

• I’m supposed to do what?

What is it?What is it?

• ResourceResource• Aggregate look at your data

ll f i• Allows for comparisons• Opportunities for completion or correction• Opportunities for improvement

Where do I start?Where do I start?• Who is the report going to?

– Administrator– Nursing– Medical RecordsMedical Records– Director– ManagerI h h i h ?• Is that the right person?

• How is it linked to the registrar• Who is reviewing itWho is reviewing it• Who is putting action around it• Where is it being reported

Where do I start?Where do I start?

• OverviewOverview– Look at the big pictureAre the numbers right– Are the numbers right

– Have your patients been appropriately captured 

C i• Case mix– How do you define your patients– Where do you find them

Inclusion: Diagnosis CriteriaInclusion: Diagnosis Criteria

• at least one ICD‐9 diagnosis code of:at least one ICD 9 diagnosis code of:• 800‐904.9, or• 925‐929 9 or 925 929.9, or• 940‐959.9, or• 994 0 (lightning strikes) or 994.0 (lightning strikes), or • 994.1 (drowning), or • 994 7 (hanging) or 994.7 (hanging), or • 994.8 (electrocution)

Inclusion: Status CriteriaInclusion: Status CriteriaTo meet the status criteria, a patient must be:• Dead

• Dead on arrival, or • Pronounced dead in the Emergency Department (even if no 

intervention performed) orintervention performed), or• Pronounced dead after receiving any evaluation or treatment 

during hospital admission, or• Acutely Transferred

• Acutely transferred into the facility, or• Acutely transferred out to another acute care facility, or

• Length of Stay• Adult patients (age > 14): Hospital length of stay > 48 hours or• Adult patients (age > 14): Hospital length of stay > 48 hours or• Pediatric patients (age < 14): Admission status of in‐patient or 

observation

Exclusionary DiagnosisExclusionary Diagnosis• isolated hip fractures• acetabular or femoral neck fractures from same level falls• Exclude the patient if they have only one ICD‐9 diagnosis 

code that meets the Diagnosis Criteria which is:code that meets the Diagnosis Criteria which is:• 820‐820.9 (femoral neck fractures), or• 808.0 (acetabular fracture closed), or• 808.1 (acetabular fracture open)

AND the patient has an E‐code of:• E885‐E885.9 (fall from same level from slipping, 

tripping, or stumbling), orE888 E888 9 ( th / ifi d f ll l l)• E888‐E888.9 (other/unspecified fall on same level).

Find your casesFind your cases

• Retrospective or prospectiveRetrospective or prospective• ICD 9 report

f i d i d i• Log of patients admitted to trauma service• ER log• OR logs

1. For all transferred patients, elapsed time between emergency department arrival and discharge to another acute care hospital does not exceed 6 hours. g p

2. For transfers with initial SBP <90 or GCS <8, elapsed time between ED and discharge to another acute care hospital does not exceed 1 hour.

For all transferred patients, elapsed time between emergency department arrival and discharge to another acute care hospital p g p

does not exceed 6 hours. 

• Is the data complete and accurate?Is the data complete and accurate?– What data elements are required for this to be accurate?accurate?

– Arrival Time– Discharge Time– Discharge Time– VSGCS– GCS

For all transferred patients, elapsed time between emergency department arrival and discharge to another acute care hospital p g p

does not exceed 6 hours. 

What are the contributingWhat are the contributing factors?

• WeatherWeather• Road conditions• No EMS rig availableNo EMS rig available• Patient unstable• Waiting for diagnosticsg g• Delay in recognition• Change in patient status

Action StepsAction Steps

• Transfer protocolsTransfer protocols• Mutual aid agreements

d i d i / f i i• Predetermined triage/transfer criteria• Education and training

A definitive airway will be established before transfer of a comatose patient (GCS < 8).  Definitive airways include: LMA, combitube, oral endotracheal 

tube, nasal endotracheal tube, tracheostomy/cricothyroidotomy. 

Are the numbers correct?Is the data complete?GCS documented?

Are procedures documented

Contributing FactorsContributing Factors

• DocumentationDocumentation– CodingGCS– GCS

• Skill level

Action StepsAction Steps

• Education and trainingEducation and training• Audit GCS (pre‐hospital & ED)G id li d l f i• Guideline development for airway management

Traumatic Brain Injury IndicatorTraumatic Brain Injury Indicator

Are the numbers correct?Is the data complete?

GCS documented?

Contributing FactorsContributing Factors

• Deterioration ‐ Patient may have initial GCSDeterioration  Patient may have initial GCS <12, but after a short period of time, the patient’s level of consciousness increased and there were no significant signs of brain injury on diagnostic tests. 

• Delay in decision to transfer• Decision to treat patient• Patient did not want to be transferred• Issue with GCSIssue with GCS

Action StepsAction Steps

• Guideline development for management ofGuideline development for management of TBI

• Transfer protocols• Transfer protocols• Predetermined triage/transfer criteria• Education and training• Audit GCS (pre‐hospital & ED)(p p )

Patients with hip, knee, shoulder, elbow or ankle dislocation receive reduction within 6 hours of ED arrival.  Excludes patients pwho died or who were discharged within 6 hours of ED arrival. 

Are the numbers correct?Is the data complete? Times documented? Are procedures documented

Contributing FactorsContributing Factors

• Other more severe injuries are being treatedOther more severe injuries are being treated first 

• No provider with available skill set• No provider with available skill set • Failed attempt to reduce• Delay in transfer• Documentation

– Times– CodingCoding

Action StepsAction Steps

• Guideline development for management ofGuideline development for management of dislocations

• Transfer protocols• Transfer protocols• Predetermined triage/transfer criteria• Education and training• Audit documentation

Missing Data ElementsMissing Data Elements

Missing ISSMissing ISS

• No diagnostics completed prior to dischargeNo diagnostics completed prior to discharge• No injuries documented

f ll i f i f i i• No follow up information from receiving facility

• No autopsy • Coding or documentation issuesg• Injury isn’t “codable”

Action StepsAction Steps

• DON’T DELAY TRANSFER • Contact the receiving facility• Give the information to your registrar!• Focus on documentation• Focus on documentation

Facility Designation Level

Trauma Coordinator/Manager Medical Director

Via‐Christi St. Francis Regional Medical Center

Level I Kris Hill, RN, MSN, ACNP(Phone) 316 268 5047

James Haan, MD, FACSRegional Medical Center (Phone) 316‐268‐5047

E‐mail: Kris_Hill@via‐christi.orgWesley Medical Center Level I Mike Valdez, RN

(Phone) 316‐962‐2264E‐mail: miguel.valdez@wesleymc.com

Paul Harrison, MD, FACS

University of Kansas Hospital

Level I Tracy Rogers, MSN, RN, CCRN, NEA‐BC(Phone) 913‐945‐6853

E‐mail: trogers@kumc.edu

Michael Moncure, MD, FACS

Stormont‐Vail HealthCare Level II Scott Harrison, RN, BSNPhone) 785‐354‐5470

Michael L. McCann, DOPhone) 785‐354‐5470(Fax) 785‐354‐5475

E‐mail: saharris@stormontvail.orgOverland Park Regional 

Medical CenterLevel II Lois Towster, ARNP, MSN

(Phone) 913‐541‐5605Robert Pruitt, MD, FACS, MBA

(Fax) 913‐541‐6820E‐mail: Lois.Towster@hcamidwest.com

Labette Health Level III Tereasa DeMeritt, RN(Phone) 620‐820‐5123

E‐mail: tdemeritt@labettehealth com

Michael Bolt MD, FACS

E mail: tdemeritt@labettehealth.comPromise Regional Level III Michelle Schrag

(Phone) 620‐665‐2580Schragmc@promiseregional.com

Via Christi Hospital‐ Level III Janelle Dimond, RN Robert Huebner MD, FACSPittsburg (Phone) 620‐232‐0159

E‐mail: janelle_dimond@via‐christi.org

NowWhat?Now What?• Include your Registrar!

– Correct any errors or omissions in documentation• Review data/results/actions

– Who manages your quality improvement or performance improvement initiativesimprovement initiatives

• ED manager• Risk Management• Quality council of Hospital• Trauma Program

– Who is this information important to in your facility?• Compare

D t & T k• Document & Track– PI Tracking form– PI Excel log

Registry– Registry