Statewide Meeting of the Executive Committees November 6, 2009 Wesley Medical Center

Transcription

1 Registration & Continental Breakfast Statewide Meeting of the Executive Committees November 6, 2009 Wesley Medical Center Jerry Jo Deckert, meeting facilitator, called the meeting to order at 8:25am. She welcomed everyone and reviewed the day s agenda and related logistics. She encouraged everyone to complete the meeting evaluation and the fun quiz included in their meeting packets. Completed quizzes were turned in for a regional drawing for six emergency preparedness bags. The emergency preparedness bags were donated by the Heartland Center for Public health and Community Capacity Development. Jerry Jo acknowledged Wesley Medical staff members Mike Valdez and Teena Johnston for their coordination of the meeting at Wesley and she acknowledged Trauma Program Staff for their work. Jerry Jo introduced Dr. William Waswick, SCKTR Chairman. He practices with Kansas Surgical Consultants, Wesley Medical Center, and Via Christi in Wichita. He completed his undergraduate work at the University of North Dakota, earned his medical degree from University of North Dakota School of Medicine, and completed his residency at Kansas University School of Medicine, Wichita Center for Graduate Studies. Welcome & Introductions Dr. William Waswick Dr. Waswick welcomed everyone to Wesley Medical Center and to the 7 th Annual Statewide Meeting of the Executive Committees. He asked all participants to introduce themselves and what they have gained being involved in the Kansas Trauma System. Public Health: State of the State Dr. Jason Eberhart Phillips Jerry Jo introduced Dr. Jason Eberhart-Phillips. Dr. Eberhart-Phillips is the Director of Health and State Health Officer with the Kansas Department of Health & Environment. He came to Kansas earlier this year after serving as the County Health Officer for El Dorado County Department of Health Services in Placerville, California. He holds his MD from the University of California San Francisco and his MPH from the University of California Berkeley. Click here to view his presentation. ACT/Trauma Program Update Dr. Paul Harrison Rosanne Rutkowski Jerry Jo introduced Rosanne Rutkowski and Dr. Paul Harrison. Rosanne Rutkowski is the Director of the Kansas Trauma Program. She received her Bachelor of Science in Nursing from Marymount College in Salina and her Master in Public Health from Wichita State University. Rosanne has been the director of the Kansas Trauma Program since Dr. Paul Harrison is the Medical Director of Trauma for Wesley Medical Center. He serves as the chairman of the Advisory Committee on Trauma (ACT) and State Chair of the American College of Surgeons Kansas Committee on Trauma. He completed his undergraduate work at Wichita State University, gained his medical degree from the University of Kansas School of Medicine, and his residency at Wesley Medical Center Click here to view presentation. Networking Break Field Triage Guidelines Dr. Scott Sasser

2 Jerry Jo introduced Dr. Scott Sasser. Dr. Scott Sasser is the first author of the Center for Disease Control and Prevention s (CDC) Guidelines For Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage. Dr. Sasser is an Associate Professor in the Department of Emergency Medicine, Emory University School of Medicine and the Hubert Department of Global Health, Rollins School of Public Health and practices at Emory University Hospital, Crawford Long Hospital, and Grady Memorial Hospital, Atlanta Georgia. Dr. Sasser is the Associate Director for International Programs for the Center for Injury Control, works as a consultant in the Division of Injury Response, in the National Center for Injury Prevention and Control, and at the Centers for Disease Control and Prevention. He is a member of the World Health Organizations (WHO) Trauma and Emergency Care Advisory Committee. Many of his publications address injury prehospital care, mass casualty incidents, and field triage. Note: CDC provided laminated post size field triage schematics and ID bag size schematics to all the participants and donated three t-shirts to be given away. Click here to view presentation. Networking Lunch The Trauma Center Medical Directors met over lunch. Using the Trauma Registry to Drive Trauma System Development: Past-Present- Future Dee Vernberg Jerry Jo introduced Dee Vernberg. Dee serves as the trauma epidemiologist with the Kansas Trauma Program. For those of you that receive your hospital s Benchmark Data Report, Dee is the one that provides the reports. Dee holds a Master s of Public Health from the University of South Carolina and a PhD from the University of Miami. Click here to view presentation. Performance Improvement: Foundation of Trauma System Development Liz Carlton Jerry Jo introduced Liz Carlton. Liz recently took a new job with the University of Kansas Hospital as the Director of Quality, Safety & Regulatory Compliance of Trauma, Burn & Transfer. She received her BSN from Texas Woman s University and her Master s in Nursing from the University of Kansas. Click here to view presentation. Networking Break Jerry Jo provided the answers to the quiz and asked everyone to turn the completed quizzes in at the registration table. Trauma Case Study Presentations Jerry Jo introduced Dr. Paul Harrison as moderator for the session and the case study presenters and review panelist. Case study presentations were provided by Dr. Michael Moncure, University of Kansas Hospital (Level I trauma center), Dr. Sonya Culver, Labette Health (Level III trauma center), and Dr. Tyson Blatchford, South Central Kansas Regional Medical Center, whose facility is working towards designation. Dr. James Haan, Via Christi Medical Center (Level I trauma center), Dr. Paul Harrison, Wesley Medical Center, (Level 1 trauma center), Dr. Robert Dodson, St. John s Hospital, Joplin, and Dr. Michael McCann, Stormont Vail Hospital, (Level II trauma center) served on the case study review panelist.

3 Dr. Don Fishman, Overland Park Regional Medical Center (Level II trauma center) was scheduled to present a case study presentation, but agenda time did not permit for his presentation. Dr. Michael Moncure is the Trauma Director at the University of Kansas Hospital. Dr. Moncure serves at the Vice-Chair of the Northeast Regional Trauma Council executive committee. He completed his undergraduate work at the University of Southern California and his postgraduate studies at the University of Washington. He completed his residency at Howard University Hospital. Dr. Don Fishman is the Trauma Director at Overland Park Regional Medical Center. He completed his undergraduate studies at University of Michigan and postgraduate studies at Rush Medical College. He completed his residency at Rush Presbyterian-St. Luke s Hospital & Medical Center, Chicago. Dr. Sonya Culver is an ER physician at Labette Health, Parsons and Wilson County Hospital, Neodesha. She completed her undergraduate studies at Pittsburg State University, her graduate studies at Kansas University Medicine and Bio Science, College of Osteopathic Medicine and her internship at Hillcrest Health Center, Oklahoma City. Dr. Tyson Blatchford is the Trauma Director at South Central Kansas Medical Center in Arkansas City. He serves as the Vice-Chair on the South Central Kansas Trauma Region executive committee. Dr. Blatchford completed his undergraduate studies at Southwestern College, Winfield, Ks and his postgraduate studies at University of Kansas School of Medicine. He completed his residency at Carilion Clinic, Roanoke, Va. Dr. James Haan is the Trauma Director with Via-Christi Hospital. He completed his studies at University of Iowa, University of Michigan Medical School and his residency at University of Iowa Hospitals and Clinics. He came to Kansas a year ago from Baltimore, Maryland. Dr. Michael McCann is the Trauma Director at Stormont-Vail Healthcare. He completed his studies at University of Wyoming and Western University of Health Sciences, Pamona, California. He completed his residency at Michigan State University-Genesys Regional Medical Center. He s the newest member of the Stormont Vail trauma team. Dr. Robert Dodson is the trauma director at St. John s Regional Medical Center, Joplin and practices with St. John s Maude Norton Memorial Hospital, Columbus, Ks. He completed his studies at Oklahoma State University and Uniformed Services University of the Health Science-F. Edward Hebert School of Medicine, Bethesda, MD and completed his residency at 81 st Medical Group, Keesler Air Force Base, Mississippi. Click here to view case study presentations. Regional Trauma Plan Review/Recommendations Dr. Dennis Allin Jerry Jo introduced Dr. Dennis Allin. Dr. Allin is with the University of Kansas Hospital. He serves as the Vice-Chair of the Advisory Committee on Trauma, the Chair of the Regional Trauma Plan Review subcommittee and is the Chair of the Kansas Board of EMS. He completed his studies at Wichita State University and University of Kansas Medical Center. He completed his residency at Thomason General Hospital-Texas Tech University. Click here to view presentation. Putting It all Together/Closing Dr. Paul Harrison Dr. Harrison reviewed the day s event, encouraged everyone to become more involved in trauma system development, and shared that he looked forwarded to working with everyone.

4 Closing Jerry Jo closed the meeting. She announced the emergency preparedness bag winners along with winners for t-shirts that were provided by CDC. A special Thank you to the Program Planning Committee: Northeast Dr. Michael Moncure, University of Kansas Hospital Lois Towster, Overland Park Regional Medical Center North Central Patricia Dowlin, Mitchell County Health Department Emma Doherty, Salina Regional Health Center Northwest Kim Nutting, Graham County EMS/Hays Medical Center Deb Kaufman, Sheridan County EMS Southwest Jerry Jo Deckert, Grant County EMS Lance McGowan, Lane County Hospital South Central Kris Hill, Via Christi Regional Medical Center Daryl Patrick, Memorial Hospital, McPherson Dr. Tyson Blatchford, South Central Regional Medical Center, Arkansas City Rita Flickinger, Harvey County Health Department Southeast Tereasa DeMeritt, Labette Health, Parsons Betha Elliott, Cherokee County Health Department AHEC Mary Beth Warren The winners of the bags were: NC Region: Dr. Pam Steinle, Smith County Medical Center NW Region: Deb Kaufman, Sheridan County EMS SW Region: Marie McEntee, Wichita County Health Center NE Region: Liz Carlton, University of Kansas Hospital SE Region: Dr. Robert Dodson, St. John s Maude Norton Hospital SC Region: Amy Wiley, Wesley Medical Center The T-shirt winners were: Michelle Schrag, Promise Regional Medical Center Frank Williams, Midwest Life Team Don Lieb, Republic County EMS Jerry Jo thanked everyone for attending, asked them to turn in their evaluations, and announced that the continuing education certificates would be mailed within the next two weeks. At the conclusion of the meeting, Rosanne Rutkowski provided a thank you basket on behalf of the Trauma Program, ACT, and Regional Trauma Council to Jerry Jo thanking her for serving as facilitator of the meeting.

5 COFFEY ANDERSON LINN Where Health Comes From Welcoming Remarks Jason Eberhart-Phillips, MD, MPH Kansas State Health Officer Regional Trauma Council Meeting November 6, 2009 Quick H1N1 Flu Update 100,000s of cases likely in Kansas so far Majority of illness is mild At least 14 deaths; at least 371 hospitalized Stresses on health care system manageable Highest incidence in school-aged children As many as 40% of KS kids already infected Aggregate Surveillance CHEYENNE RAWLINS DECATUR NORTON Kansas Counties with Laboratory-Confirmed Cases of H1N1 Influenza A Week Ending October 24, 2009 PHILLIPS SMITH JEWELL REPUBLIC WASHINGTON MARSHALL NEMAHA BROWN DONIPHAN ROOKS SHERMAN THOMAS SHERIDAN GRAHAM WALLACE LOGAN GOVE TREGO ELLIS OSBORNE MITCHELL LINCOLN RUSSELL ELLSWORTH CLOUD ATCHISON JACKSON CLAY POTTAWA- TOMIE JEFF- OTTAWA ERSON LEAVEN- RILEY WORTH SHAWNEE WYAN- DOTTE DICKINSON GEARY WABAUNSEE SALINE JOHNSON MORRIS OSAGE DOUGLAS GREELEY WICHITA SCOTT LANE NESS RUSH BARTON MCPHERSON MARION LYON FRANKLIN MIAMI RICE CHASE PAWNEE HAMIILTON KEARNEY FINNEY HODGEMAN STAF- FORD RENO HARVEY GRAY EDWARDS SEDGWICK BUTLER GREENWOOD WOODSON ALLEN BOURBON FORD STANTON GRANT HASKELL KIOWA PRATT KINGMAN WILSON NEOSHO CRAWFORD ELK MORTON STEVENS SEWARD MEADE CLARK COMANCHE BARBER HARPER SUMNER COWLEY MONT- LABETTE CHAUTAUQUA GOMERY CHEROKEE This is Not an Ordinary Flu! Disease Control Strategies % H1N1 Hospitalizations Through August 21, 2009 Compared to Expected Age Distribution for Seasonal Flu 28% 18% 15% 13% 13% 15% 14% 0-4 yrs 5-24 yrs yrs yrs >65 - yrs 6% 45% Our objectives at KDHE: Decrease the risk of hospitalization and death Minimize social and economic disruption Surveillance Community mitigation Social distancing, school/ work exclusion, education Immunization/Treatment New H1N1 flu vaccine

6 H1N1: This Week s Problems Vaccine supply Half of predicted amounts Huge unmet demand Antiviral supply Oral suspension drying up Overuse; resistance risk Spot shortages of PPE Messaging challenges Prioritization rationale Safety and effectiveness Chicago on Fire, 1871 America on Fire, 2009 US has the highest rate of preventable deaths in its class More than half of Americans live with >1 chronic diseases Health care costs are skyrocketing: $2.4T Now 1/6 th of GDP It s the largest single household expense This isn t sustainable 78% increase since : 1% of federal budget Today: 20% and growing! Fed health care spending 8 times that for education 12 times: food aid 30 times: law enforcement 78 times: land management 87 times: drinking water 830 times: energy saving Systems Model of Health Systems Model of Health Becoming no longer vulnerable Becoming no longer vulnerable Demand for response Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Adverse Living Conditions Dying from Complications Adverse Living Conditions Dying from Complications Source: Milstein & Homer 2003 Source: Milstein & Homer

7 Systems Model of Health Systems Model of Health General protection Targeted protection Becoming no longer vulnerable Primary prevention Secondary prevention Tertiary prevention Demand for response General protection Targeted protection Becoming no longer vulnerable Primary prevention Secondary prevention Tertiary prevention Demand for response Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Adverse Living Conditions Dying from Complications Adverse Living Conditions Dying from Complications Source: Milstein & Homer 2003 Source: Milstein & Homer 2003 Systems Model of Health Systems Model of Health General protection Targeted protection Becoming no longer vulnerable Primary prevention Secondary prevention Tertiary prevention Demand for response General protection Targeted protection Becoming no longer vulnerable Primary prevention Secondary prevention Tertiary prevention Demand for response 96% Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Safer, Healthier Population Becoming vulnerable Vulnerable Population Becoming Afflicted Afflicted without Complications Developing Complications Afflicted with Complications Adverse Living Conditions Dying from Complications Adverse Living Conditions Dying from Complications Source: Milstein & Homer 2003 Source: Milstein & Homer 2003 Least Among Great Nations In the WHO s 2008 health rankings of 31 industrialized nations, the United States is Tied for last in healthy life expectancy (67 yrs) Worst in infant mortality (7/1000 live births) 20 th in age-adjusted cardiovascular mortality 14 th in age-adjusted cancer mortality First by far in female obesity prevalence (33%) First by far in male obesity prevalence (31%) Third lowest adult smoking prevalence (23%) Healthcare quality also below expectations A Disease-Based Economy Healthcare is fastest growing and strongest sector of the economy Highest paying, most secure jobs High growth potential with escalating demand Expanding markets for pseudo-diseases Strong economic disincentive for prevention 3

8 Is it a Commodity or a Right? Health care acts like a business Services aimed at paying clients Marketing care, creating demand Systematically excludes people 48 M uninsured 25 M under Solution: More Health Care? It s how the question is usually framed The supply of services is too low to meet need More spending on more clinics, hospitals, docs Need to screen more people, to get more people into treatment Everyone gets what those with the most get More Isn t Always Better Quantity Doesn t Mean Quality In regions with more hospitals and doctors health care is worse! Worse outcomes Heart attacks, fracture of the hip, colon cancer Worse access Greater waiting times Lower satisfaction Worse communication The Answer Isn t Health Care We have to turn our attention upstream Change the conditions at the root of most common diseases Create environments that support optimal health, quality lives Physical environments Social environments 12 Factors = 5,416 Deaths/day Source: Danaei G, Ding EL, Mozaffarian et al, ,977,000 deaths/year 4

9 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 (*BMI 30, or about 30 lbs. overweight for 5 4 person) Obesity: Medical Complications Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Idiopathic intracranial hypertension Stroke Cataracts Coronary heart disease Diabetes Dyslipidemia Hypertension No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Gall bladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gout Severe pancreatitis Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Childhood Obesity Obesity among US kids is rapidly increasing Since 1980 child obesity has more than tripled 25 million are now obese or overweight Obesity is defined as >95 th percentile on agesex specific BMI chart Overweight: >85 th %tile Alarming Trends Only 54% of high school students have a PE class at least once per week >35% of teens watch TV for >3 hours/day; >20% play video games for >3 hours/day Sugar intake has grown 22% since 1985 Spending in fast food restaurants has increased more than 18 times since million teenagers now have pre-diabetes Up to 45% of childhood diabetes is Type 2 Failure Isn t an Option Obese kids may have Low self-esteem, poor academic performance More likely to develop high blood pressure, diabetes, liver disease, sleep apnea as adults 60% already have a cardiovascular risk factor; 25% have two Early mortality likely Kansas High School Kids 25% of 9 th to 12 th graders are overweight or obese 79% don t get >5 servings of fruits or vegetables/day 33% have consumed >1 can or bottle of soda daily for the past seven days 55% don t get an hour of physical activity at least five times per week 26% watch TV for >3hrs/day 5

10 A Medicalized Response? NO! There will never be enough surgeons or prescription drugs to end the obesity crisis We aren t in this crisis because of shortages of health care! Problem is upstream, and so is the solution The Problem is Environmental In America today it s hard not to get fat Obesity is designed into our daily lives Abundant high-energy foods at low cost Fewer opportunities for intrinsic physical activity Barriers to engage in active transport, in utilitarian movement The Solution is Environmental How can we make it easy for people to make the right choices? If only 10% of sedentary Americans could walk for 30 minutes a day, we could save $5.6 billion in heart disease treatment Where can they walk? Can we build walking into their daily lives? A World Built for Cars Today s street networks cut out option of walking/biking One-fourth of all trips are less than one mile in length, but 75% are made by car Trips taken by foot have dropped 42% in 20 years Only 22% of California adults walk for >150 min/week 27% never walk at all! Huge regional variations International Comparisons Walking/Biking to School Once common 50% in 1969 Less than 15% today Many benefits Encourages physical activity, fun in walking Raises concern for the environment Reduces local crime Cuts down on traffic congestion, pollution and speed near schools 6

11 Build It And They Will Come Retail Food Environment Index Residents meeting recommended activity levels 43% 27% safe places to walk no safe place to walk within ten minutes of home Powell et al., AJPH, 9/03 Measures a community s retail food environment Using GIS, can compute RFEI for a radius around BRFSS respondent s home California average is 4.5 Wide variations by locality Strong racial, income links The RFEI-Obesity Connection Looking Close to Home Topeka, KS No commercial center Little mass transit High auto dependence Few mixed land uses Few healthy food options in lower income neighborhoods Abundant fast food, snack and liquor outlets 3 rd floor office Elevators are very inviting Easy to find, well-lit, clean Stairs are there for emergency exit, primarily Need a key card for access Closer to Home Three Environmental Initiatives School vending Sugary drinks, cookies, candy, chips sell most KS one of 20 states with no regulations Require such healthy alternatives as water, milk, fruits/vegetables Need to send kids an unambiguous message Other funding needed 7

12 Menu Labeling Require fast food chains to post calorie counts at the point of purchase Is already available on store-bought foods Provides transparency; gives people information to make their own choice Early studies show it does influence choice Direct costs are trivial Sugar-Sweetened Beverages Taxes the single largest driver of obesity epidemic Average intake has nearly tripled since 1978 Marketed to children/teens Displaces healthier drinks Relative cost has fallen Penny per ounce would cut consumption >10% Also a revenue source Primary Seat Belt Law We will keep trying Would increase use by 12 to 22.6 percent Would save 140 to 158 lives in its first year Prevent 2,190 serious injuries in car crashes Save $440-$485 million This is too high a price for so-called freedom Future Trauma Initiatives Motorcycle helmet law Would save ~ 8 lives annually; $2.7 million in medical costs Might end the state s status as a net exporter of organs for transplant Bicycle helmet law Could be preventing 22 traumatic brain injuries annually in Kansas Chicago 25 years After the Fire Thank You For Listening! To Protect the Health and Environment of all Kansans by Promoting Responsible Choices 8

13 Kansas Trauma System Past, Present, Future Paul B. Harrison, MD. FACS Rosanne Rutkowski, RN, MPH Chair, Governor's Advisory Kansas Trauma Program Committee on Trauma Director Objectives Trauma System Development Past & Present National State Current Status Regional Trauma Councils Discuss Future Plans Trauma System Development Early Years Earliest focus was on safe, comfortable trip Why rush to the hospital? No emergency treatment on arrival No defibrillation or trauma surgery 1920s Vehicle Code: After a collision... transport the injured in whichever vehicle still operates... Trauma System Development 1966: Highway Safety Act (reduce highway injuries) 1973: EMS Systems Act ( EMS infrastructure) 1976: ACS Optimal Care for the injured 1986: Injury in America Injury Center CDC 1988: NHTSA assessment teams 1994 NHTSA Assessment Kansas 1990: Trauma Care Systems & Development ( funded & ) Kansas EMS/Trauma System Planning Project: Goals of the Kansas Trauma System Reduce the number of preventable deaths Improve outcomes for traumatic injuries Encourage provider preparation and response to trauma Reduce medical costs through appropriate use of resources Increase public awareness & prevention Design an inclusive and comprehensive system Develop trauma education resources Kansas Trauma Plan 2001

14 ACS Green Book: 2006 National guidelines--- State/local implementation American College of Surgeons Committee on Trauma (ACS/COT Model Trauma System: 1992 West Components: 2002 Authority to designate? Formal process for designation? Limit on number of trauma centers? Outside visit required for verification? Are there written prehospital protocols to transport to trauma center? Do you utilize standards (ACS)? Do you have a trauma registry? Ranking of States According to West Criteria Ranking of States According to West Criteria

15 Model Trauma System: 2006 Model Trauma System Planning and Evaluation Promote improvements in outcome from traumatic injury through prevention, education, research and continued improvement in systems of care Public Health Approach to Trauma System Planning & Evaluation Public Health Approach Assessment- ID the problem and conduct surveillance Policy Development- develop policies, plans and mobilize the community Assurance- Enforce laws and evaluate trauma system effectiveness Surveillance: What is the problem? Risk identification: What is the cause? Intervention: What works? Implementation: How do you do it? Outcome measurement: Did it work? State Trauma System Assessment August, 2008 Top Ten Priorities Identified Stakeholder self assessment of the system Facilitated by outside team of trauma system experts Identified priorities 302.8: Transportation resources 303.4: Organized transportation to appropriate level of care : Prehospital triage criteria 203.5: Injury prevention plan 207.4: Public information 310.5: Nursing trauma education 310.8: Physician trauma education

16 Advisory Committee on Trauma member committee 6 members RTC representatives 4 Legislative representatives Nominated by organization Appointed by the Governor Governor s Appointment: 2009 Appointments: Pam Kemp- Clay Center Dr. Craig Concannon- Beloit Cathy Heikes- Dodge City Kris Hill- Wichita Terry Siek- Hays John Ralston- Liberal Current Projects: 2009 Address BIS Assessment Support Level III trauma centers Develop Level IV criteria Update Regional Trauma Plans Update Data Benchmark Report 2009 Annual Report State Trauma Medical Director s Committee Proposed Level IV criteria: Trauma Team Transfer/Communication Plan Equipment for resuscitation Quality improvement program Transfer protocol Why a trauma system is needed: Unintentional Injuries: Then: ,124 Unintentional Injury Deaths 536 deaths from MVC Unintentional injury death rate 42.4 deaths per 100,000 population Unintentional Injuries in Kansas Leading cause of death for Kansas residents 1 to 44 years of age Injuries account for 74% of the deaths in the age group Now: ,256 Unintentional Injury Deaths 364 deaths from MVC Unintentional Injury death rate 44.8 deaths per 100,000 population 17.9 Percent higher than in 1988

17 Regional Trauma Councils Cornerstone of the state system Responsible for assessing regional resources Responsible for identifying educational needs and providing education Responsible for community prevention efforts An opportunity for input into the state system Opportunity to become involved at regional level Regional Trauma Councils: Contract transitioned from KFMC 2007 Regional Trauma Councils have been funded at $20,000 Fiscal agents for each of the six regions NC- Mitchell County Hospital NW- Hays Medical Center SW- Bob Wilson Hospital SC- Promise Medical Center SE- Mount Carmel Regional Medical Center NE- Stormont-Vail HealthCare 2008 RTC Budget: $120,000 1% 3% 7% 9% 18% 12% 50% Education Prevention Meetings PI Planning Other Administrative Regional Trauma Education 2008 TNCC:67 ATLS: 36 RTTDC: 95 PHTLS: TNCC: 110 ATLS: 38 RTTDC: 103 PHTLS: 112 EMS Med. Dir: 15 EMD: 16 SC Regional Trauma Council: Injury Prevention: Falls, Teen Driving 2009: $5,000 Education: ATLS, PHTLS, TNCC 2009: $14,000 Other: Strategic Planning, meetings 2009: $3,600 NE Regional Trauma Council: Injury Prevention: fall prevention 2009: $3,600 Education: 2009: $17,000 Other activities: EMD 2009: $4,000

18 NC Regional Trauma Council: Injury Prevention: Community grants 2009: $1,500 Education: TNCC instructor class 2009:$16,000 Other: EMD Banquet, strategic plan 2009 $4,025 SE Trauma Council: Injury Prevention: community grants 2009: $2,700 Education: ATLS 2009: $15,700 Other: 2009:$3,150 NW Regional Trauma Council: Injury Prevention: Fall grants 2009: $3,000 Education: EMS scholarships 2009: $14,500 Other: 2009: $2,000 SW Regional Trauma Council: Prevention: 2009: $2,500 Education: ITV meetings 2009:$14,850 Other: 2009: $1,190 Regional Meetings: Kansas Trauma Program Staff Rosanne Rutkowski, RN, MPH Program Director Dan Robinson Assistant Program Coordinator Dee Vernberg, PhD, MPH Trauma Epidemiologist Jeanette Shipley Regional Trauma Coordinator Dan Russell Database Administrator

19 Kansas Trauma Program Website: ACT Regional Trauma Council Education Regulations Publications Contact information Newsletter Fall 2009 Newsletter Kansas Trauma System Future Paul B. Harrison, MD. FACS Chair, Governor's Advisory Committee on Trauma Future Directions Continue support trauma center development Promote adoption of CDC field triage guidelines statewide Assess education needs for trauma Programs/resources based on data Promote EMD Link EMS & Trauma Registry Data Level IV Designation Criteria has been developed Define the survey process Write & approve regulations Recent Accomplishments: Salina Regional Medical Center Most recent facility pursuing Level III Labette Health Recently designated Level III trauma center

20 Field Triage Guidelines Encourage EMS services adopt CDC field triage guidelines Standard of care for Kansas Better utilization of limited resources Training & Education Establish min. standards for trauma care Prehospital PHTLS Nurses TNCC Physicians ATLS Hospitals Rural Trauma Team Development (RTTDC) Trauma Registry Data: Promote use of data to drive injury prevention Falls & teen driving Track Over & Under Triage Performance Improvement Kansas Trauma System Summarize: 1) Progress has been made. 2) We strive to put ourselves out of a job. 3) Lets go to the next level in developing the Kansas Trauma System. Thank you for your support

21 Page 1 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Field Triage Decision Scheme: The National Trauma Triage Protocol U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Injury Response Objectives Objectives Review the importance of accurate field triage Review the history of the American College of Surgeons Field Triage Decision Scheme Discuss changes in the 2006 Field Triage Decision Scheme Review CDC educational initiatives for the 2006 Field Triage Decision Scheme Page 2 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Published: January 2009 Available for FREE at: Page 3 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Source: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Webbased Page Injury 4 Source: Statistics American Customer Query Satisfaction and Reporting Index, Oct. System. 4, 2008 Jan. Ten 31, Leading 2009 Causes of Death, History of the Decision Scheme If you are severely injured, care at a Level I trauma center lowers your risk of death by 25%. The American College of Surgeons-Committee on Trauma (ACS-COT) developed guidelines to designate trauma centers in Set standards for personnel, facilities, and processes necessary for the best care of injured persons Studies showed mortality reduction in regions with trauma centers Source: MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of traumacenter 5 Source: care American on mortality. Customer Satisfaction N Engl Index, Oct. J Med. 4, Jan. Jan 31, ; Page 354(4): Page 6 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

22 Page 7 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 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 Scheme serves as the basis for field triage of trauma patients in most EMS systems in the U.S. History of the Decision Scheme The Decision Scheme has been revised four times (1990, 1993, 1999, 2006) In 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 Page 8 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 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 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 Page 9 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 10 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Why this Decision Scheme is Unique Field Triage Decision Scheme: The National Trauma Triage Protocol 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 Page 11 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 12 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

23 Page 13 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 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 Step 1: Physiologic Criteria Page 14 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 1: 2006 Changes Added A threshold for respiratory rate (<20 bpm) in infants Removed Revised Trauma Score Step 2: Anatomic Criteria Page 15 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 16 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 2: 2006 Changes Added Crushed, degloved, or mangled extremity Modified Open and depressed changed to open or depressed skull fracture Removed Burns moved to Step Four Step 3: Mechanism of Injury Criteria Page 17 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 18 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

24 Page 19 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 3: 2006 Changes Added Vehicle telemetry data consistent with high risk of injury Time Out What is vehicle telemetry? Combination of telematics and computing Integration of vehicle s electrical architecture, cellular communication, GPS systems, and voice recognition Can notify of exact location of crash Can enable communication with occupants Can provide key injury information to providers regarding force, mechanics, and energy of a crash that may help predict severity of injury For more information, visit: Page 20 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 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 Step 3: 2006 Changes Modified 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 Page 21 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 22 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 3: 2006 Changes Removed Rollover crash Extrication time >20 minutes Crush depth Vehicle deformity >20 inches and vehicle speed >40 mph Step 4: Special Considerations Page 23 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 24 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

25 Page 25 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 4: 2006 Changes Added Burns (moved from Step Two) Time-sensitive extremity injuries End stage renal disease requiring hemodialysis EMS Provider judgment Step 4: 2006 Changes Modified Age Older adults: Risk of injury/death increases after age 55 Children: Should be triaged preferentially to pediatric capable trauma centers Pregnancy changed to read Pregnancy greater than 20 weeks Page 26 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 4: 2006 Changes Removed Cardiac and respiratory disease Diabetes Mellitus Morbid obesity Immunosuppression Cirrhosis Education Initiative CDC, in collaboration with partners and experts, has developed FREE educational tools: MMWR report and continuing education opportunity laminated ambulance poster laminated binder insert for training or protocol binders badge with the decision scheme to clip to uniform large poster pocket card electronic mapping tool (widget) that shows the location of trauma centers nationwide, Recorded Webcast with CDC experts, and video podcast. FREE Continuing Education Opportunity at And more resources are to come Page 27 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 28 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Endorsing Organizations Endorsing Organizations With concurrence from the National Highway Traffic Safety Administration Page 29 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 30 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

26 Page 31 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 References 1. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Ten Leading Causes of Death, MacKenzie EJ, Rivara FP, Jurkovich GJ, Nahens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med Jan 26; 354(4): Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage. MMWR 2009; 58 (1): For more information or to access FREE materials, visit: Page 32 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 33 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009

27 Using the trauma registry to drive trauma system development: Past- Present-Future Agenda Brief History of Kansas Trauma Registry Intent of creating & maintaining State Registry Trauma Surveillance as framework Describe the Kansas Trauma System Patient flow in system Data quality & why you should care Data Report indicators Over and under triage of transferred patients Broad goals for future Kansas trauma system is unique Inclusive trauma system Engage all acute care facilities in the care of injured patients State designated and ACS verified trauma centers Other hospitals that treat trauma All acute care hospitals that treat trauma have a registry & report data to the state Trauma Registry part of Statewide system from the beginning Kansas Statewide Trauma System is relatively new 1999 legislation enacted authorizing Kansas Trauma System 2001 Collector was distributed to the 9 participating hospitals 2002 Data dictionary developed Phased in trauma registry training Trauma registry - Highlights 2003 First download of data to central site 1 st trauma registry sub-committee meeting 2004 Inclusion criteria changed to include children 2006 web based registry introduced Role of Trauma Registry System performance improvement Needs assessment Epidemiologic purposes Statewide or regional research projects

28 Trauma Registry describes system Elements of Trauma Surveillance Who, where, what, how injured Trauma Patients Was EMS involved? EMS times EMS treatments Evaluate Trauma Registry Collect & Process Data Outcome Cost Payor Source Hospital patient treated Injury diagnosis & severity Clinical indicators, comorbidities, complications Treatments Who cared for patient Times?Transferred Use Results to plan interventions or treatment Analyze & Interpret Data Report Results Groups in Trauma System Infrastructure Trauma Registry Reporting: initial & ongoing focus Surveillance system Information to make decisions at local level Flexible in order to answer questions Intent of having state registry Describe trauma system Describe trauma patients System performance review issues Identify where to direct resources Research projects Hospitals in Trauma System 126 hospitals in Kansas Trauma System 3 hospitals with registries in hospital with registry that has never reported cases that meet trauma inclusion criteria since 2005 Hospitals reporting cases that meet inclusion criteria 2005 : 114 hospitals 2006 : 119 hospitals 2007 : 117 hospitals 2008 : 115 hospitals 2008 hospitals reporting 0 cases that meet inclusion criteria 8 hospitals reporting 0 cases that meet inclusion criteria Other trauma hospitals reported receiving transfers from 7 of these 8 hospitals Under-reporting How to address this? Communicate back with hospitals

29 KTR data set Kansas trauma system patient flow Overall Records Included 87.7% 89.9% 90.1% 87.1% Incident Records *Provisional Counts - data refreshed November, 2009 Other facilities 334 pts. Nursing home, clinics, jail, rehabilitation, other out-ofstate Out-of-state trauma centers 74 pts. 2, ,984 Out-of-state trauma centers 298 pts. Transfers between non-designated 496 pts. Reporting Past and present Accept the number of cases hospitals report Ask hospitals if they have cases Any number of cases or report of 0 cases is counted as reporting Future Start looking at under-reporting Transfers Ask out-of-state trauma systems how many transfers from Kansas hospitals How data drives system Findings should stimulate discussion Reporting and data collection How complete and good are the data? How system is working (PI) Transfers Treatments Identifying where resources are needed Describing trauma patients How good are the data? Evidence of missing data and improvement in data collection Are there missing data? Elements of Trauma Surveillance Evaluate Trauma Registry Use Results to plan interventions or treatment Trauma Patients Report Results Collect & Process Data Analyze & Interpret Data Are all hospitals reporting? # records EMS Run Sheet Completeness Arrived at hospital from scene or home, valid EMS mode 59.3% 42% 10.7% 28.5% 40.9% 60.2% 71.8% Missing Never received Illegible Incomplete Complete not timely Timely & Complete Change in data collection practices? Groups in Trauma System Infrastructure Valid EMS mode- land or air transport EMS run sheets important for describing transfer time to hospital & treatments in field

30 GCS documentation GCS Documentation EMS report complete % records with documentation ED & EMS GCS Documentation Kansas Trauma Registry, ED GCS EMS GCS # records with documentation ED & EMS GCS Documentation Kansas Trauma Registry, ED GCS EMS GCS EMS GCS complete record SBP Documentation ED & EMS SPB Documentation Kansas Trauma Registry, ED SBP EMS SBP SBP Documentation EMS Report Complete ED & EMS SBP Documentation Kansas Trauma Registry, ED SBP EMS SBP EMS SBP complete record % records with documentation % records with documentation Trauma Registry Findings Discussions about data quality Hospitals reporting Data quality Missing data bias descriptions Improvement in data collection Describe the trauma system Cases reported Performance improvement indicators Care about data quality because use these data

31 Data report indicators describe system Information about some procedures or treatments Information about transferred patients Transfer Indicators Performance Improvement For transfers with initial SBP < 90 or GCS < 8, elapsed time between ED and discharge to another acute care facility does not exceed 1 hour. A definitive airway will be established before transfer of a comatose patient (GCS < 8) Patients with suspected traumatic brain injury (moderate or severe coma, GCS<12), are transferred to a level I or level II center for treatment. Other transfer indicators For all transferred patients, elapsed time between ED arrival and discharge to another acute care facility does not exceed 6 hours. Patients with pneumothorax (or hemopneumothorax) receive a chest tube before transfer to another acute care facility. Hospital Treatment Indicators Patients with hip, knee, shoulder, elbow or ankle dislocation receive reduction within 6 hours of ED arrival. Patients with low-grade splenic laceration, (AIS < 3) do not undergo splenectomy. Patients with penetrating abdominal injury and SBP < 90 undergo laparotomy within 60 minutes of ED arrival Time to transfer indicators Time to transfer patients Transfer time indicators Kansas Trauma Registry, Transfer <= 6 hours Unstable transfer <= 1 hour % meeting indicator

32 Brain Injured Patient Transfers Other indicators % meeting indicator Brain Injury Transfers Kansas Trauma Registry, Airway for GCS <=8 To Level I or II for GCS <= Chest Tube: Patients with pneumothorax (or hemopneumothorax) receive a chest tube before transfer to another acute care facility Dislocation: Patients with hip, knee, shoulder, elbow or ankle dislocation receive reduction within 6 hours of ED arrival. Spleen: Patients with low-grade splenic laceration, (AIS < 3) do not undergo splenectomy. Hypovolemia: Patients with penetrating abdominal injury and SBP < 90 undergo laparotomy within 60 minutes of ED arrival Trauma Registry Findings Discussions about data quality Describe the trauma system Cases reported Performance improvement indicators Over and under triage of transferred patients Overtriage & Undertriage Overtriage patient transferred to Level I or II center who may not have needed to be transferred Undertriage Unstable patient who could have been transferred to Level I or II trauma center and was not Overtriage Patients who are transferred to Level I or II trauma center and discharged <= 24 hours PI Filter Trauma registry data are imprecise Level I or II hospitals look at records to determine if real overtriage or not Look at Level I or Level II trauma center records Transferred patients who discharged <= 24 hours are overtriaged Hospitals referring to Kansas Level I & II trauma centers All patients who arrived at Level I or II hospital from referring hospital Kansas Trauma Registry , 11% 157, 10% 24, 2% 1241, 77% Other Kansas Trauma Hospital Kansas Non-trauma hospital Out of state hospital Miscodes/other Missing- n=4

33 Overtriage All Hospitals Overtriage Kansas Hospitals Hospital days for patients who arrived from referring facility to Level I or II trauma centers Kansas Trauma Registry Hospital days for patients transferred to Level I or II hospitals from referring Kansas Trauma Hospitals Kansas Trauma Registry , 15% 115, 7% 322, 20%,Overtriage measure 197, 16% 81, 7% 257, 21% 914, 58% 24 hours or less 2-7 days 8-14 days >14 days 706, 56% 24 hours or less 2-7 days 8-14 days >14 days Undertriage Level III and non-designated hospitals Unstable patients will be transferred to Level I or Level II trauma centers ED SBP <90 or ED GCS <=8 are transferred to Level I or Level II trauma center Who are potentially undertriaged? Undertriage ED SBP<90 or ED GCS < 8 Non-Level I or II Trauma Centers Unstable patients Death in Transfer acute Nursing Rehab Home/health Other hospital care home/skilled care Hospice, Specialty, Mental Health, Other Discharge to categories Preliminary findings 2008 data Exclude DOA, death in ED # patients Undertriage ED SBP < 90 or ED GCS < 8 Non-Level I or II Trauma Centers Unstable patients outliers Death in Transfer acute Nursing Rehab Home/health Other hospital care home/skilled care Hospice, Specialty, Mental Health, Other Discharge to categories Preliminary findings 2008 data Exclude DOA, death in ED # patients Undertriage Unstable patients to acute care facility 30 patients discharged to non-acute care hospital Non-Level I and II Trauma Centers that transferred patients to acute care facility Kansas Trauma Registry Not Level I, II KS Level I, II Out of state Level I, II 63, 17% 194, 51% 123, 32% Undertriage N= data Preliminary findings

34 Undertriage Unstable pts non Level I or II hospitals Undertriage Unstable pts transferred to Level I or II Discharge to acute care hospital or Death in hospital Kansas Trauma Registry , 29% Death in hospital Level I or II Not Level I or II 41, 10% 257, 61% # patients Non-Level I or II Trauma Centers Unstable patients outliers outliers outliers outliers outliers 410 Some outliers 41 Death in hospital Transfer acute care Nursing home/skilled Rehab Home/health Other care Hospice, Specialty, Mental Health, Other Discharge to categories 2008 data Exclude DOA, death in ED Undertriage Trauma Registry drives the system Unstable patients non-level I, II trauma centers Kansas Trauma Registry Provide Training Elements of Trauma Surveillance Trauma Patients Describe trauma patients Undertriage n=257 29% Level I or II n=629 71% 41 Death in hospital 123 Transfer non Level I or II 248 Home or home w/care 203 (not acute care: mental health, nursing facility/home, rehab, specialty, hospice) 14 Other Modify data elements to answer questions Use data to target prevention programs Evaluate Trauma Registry Use Results to plan interventions or treatment Collect & Process Data Analyze & Interpret Data Reporting Data quality Describe trauma system Report Results 2008 data Exclude DOA, death in ED Not included: Two non-medical transfer, 1 missing dis_to, 30 not acute care hospital Findings to hospitals (encourage PI) Groups in Trauma System Infrastructure Findings stimulate discussions Future goals 1. Improve EMS data collection 2. Times missing data 3. New data element Describe regional systems Questions? Over and Under triage 1. Encourage & support PI 2. Support Level III & IV verification Dee Vernberg, Ph.D., M.P.H. Trauma Epidemiologist Kansas Trauma Program dvernberg@kdheks.gov

35 Objectives Performance Improvement: Foundations of Trauma System Development Elizabeth Carlton, MSN, RN, CCRN November 6, th Annual regional Trauma Council Meeting of the Executive Committees List the primary components of Trauma specific Performance Improvement & Patient Safety Program Develop a performance improvement plan utilizing the trauma registry as its foundation Implement methods to utilize registry data to promote & support the trauma program Articulate the importance and process of loop closure What s in a Name? That which we call a rose by any other name would smell as sweet. Quality Assurance - QA Quality Improvement - QI Performance Improvement - PI Process Improvement - PI Continuous Quality Improvement CQI Total Quality Assurance/Improvement TQI/A PIPS: Performance Improvement & Patient Safety

36 PIPS (ACS Trauma Wikipedia ) Chapter 16 of the Resources for Optimal Care of the Injured Patient Manual describes the concept of monitoring, evaluating, and improving the performance of a trauma program. Although there is no precise prescription for trauma performance improvement and patient safety (PIPS),ACS-COT requires a structured effort by a trauma program to demonstrate a continuous process for improving care for injured patients. #1 Reason Hospitals Fail Verification! INEFFECTIVE PERFORMANCE IMPROVEMENT PROGRAM Why Do Performance Improvement? Our patients quality patient care is a priority It s the right thing to do Desire/need to provide a quality product Staff empowerment, ownership and satisfaction Regulatory & Accreditation Agencies TJC CMS Public reporting of hospital data Pay for performance TRAUMA ACCREDITATATION The definition of insanity is doing the same thing over and over and expecting different results

37 Trauma PIPS Patient focused: systematic evaluation of the care of each patient Data driven Education Identify needs Evaluate impact of intervention Prevention Identify target group (ECode: MVC, intersections) Analyze target data (demographics, location) Evaluate effectiveness (measurable outcomes) Grants Funding Research Trauma PIPS: Outcomes Based Excellence in patient care Patient satisfaction Evidence based practice Utilization review process Trauma center designation System enhancement Champions Data Process Critical Components Critical Components Champions Trauma Program Manager Trauma Medical Director Liaisons Link to Hospital Organizational Improvement Risk Management Board Data Collection Management Critical Components Trauma Registry Data repository Evaluation of patient care Drives PI Summation & review of trends Track variability and improvements Measure variable for progress Resource for utilization review

38 Data Manager Data Collection Trauma Registrar/PI Coordinator/Trauma Program Manager Chart analysis Abstraction Data entry Review Reporting Retrospective VS Abstractions from charts, registry forms Analyzed later May be paper dependant Pro Complete all at once Whole picture Easier Con Heavy reliance on medical records Not timely Feedback less effective Slow Concurrent Data recorded in real time More accurate Labor intense Pro Impact patient care at point of service satisfaction reliance on medical records Accuracy Duplication Con Resource intense Access to charts (inpatients are busy!) Management of data Data Validity Only as good as what you put in it Establish internal validity ensure accuracy of data entered into the trauma registry monthly data review of selected charts The minimum percentage of accuracy should be 95%. Develop standard reports What to collect? Scene Management Scene time Missing/Incomplete run sheets Care management Airway Immobilization Temperature control Transfers Transfers in/out N ISS Management Timeliness Rationale Follow-up Transfer Patterns What to collect? What to collect? Trauma Activations Attending response time Activation changes Over triage/under triage Documentation Care management Airway Fluid Management MTP Time Operating Room Time to OR Orthopedic urgent vs emergent access Resuscitation management ICU Re-Intubations (Within 48hrs) Readmissions LOS Protocol management Vent days Pediatric Admissions Inpatient floor Non-Surgery Service Trauma Admission Protocol management Pain control Patient satisfaction LOS

39 What to collect? Discharge Seen in ED, DC'd, admitted within 72hours Readmission Missed injuries Trauma deaths Complications Pneumonia VTE/PE Decub Wound infection UTI Delay in treatment Missed diagnosis Compartment syndrome Hardware or graft failure Sepsis Management Process Traumatic Brain Injury Pre-Hospital Airway mgt Episodic hypoperfusion Disposition ED Resuscitation Timing of interventions ICP/Licox placement NS response Pharmaceutical management Time to OR for definitive head management Coumadin protocol in TBI s C-spine Clearance Scene Appropriate immobilization Assessment ED Radiographs Collar Timeliness Clearance Definitive Diagnosis Service Specific Radiology Grading of solid organ injuries Misreads/Over reads Delay in diagnosis DX due to error Timeliness CT MR Interpretation Scene Referral Facility ED OR Radiology Lab/Blood Bank ICU Floor Clinic Continuum of Care Indicators Choose appropriate filters for your facility Monitor compliance with algorithms for care System issues vs. provider Action required

40 Critical Components Process Model Forum PI Committee Peer Review Committee Determination & Action Loop Closure Quality Assurance Focused Audit Process Indicators Trends Filters PATIENT DATA OUTCOMES Performance Improvement Issue Identification Analysis Action Plan Implementation Evaluation Problem Solving Follow up Loop Closure Excellence in Patient Care Patient Satisfaction Evidence based Practice management guidelines Benchmarking Internal State National System Enhancement Trauma Center Designation Financial Responsibility Utilization Review Education Prevention Research The Performance Improvement Process CONSIDER INSTITUTIONAL CONTEXT MISSION GOALS STRATEGIES CULTURE CLIENT and COMMUNITY PERSPECTIVES GET and MAINTAIN STAKEHOLDER AGREEMENT DEFINE DESIRED PERFORMANCE GAP DESCRIBE ACTUAL PERFORMANCE FIND ROOT CAUSES Why does the performance gap exist? SELECT INTERVENTIONS IMPLEMENT What can be done INTERVENTIONS to close the performance gap? MONITOR AND EVALUATE PERFORMANCE PLAN Identify & Analyze the Problem DO Develop & Implement Solutions CHECK Evaluate The Results ACT Standardize The Solution Performance Improvement Committee Systems Based Multidisciplinary with attendance requirements Recognized by the hospital and medical staff PI Committee Membership: Trauma director Trauma surgeons Trauma program manager Nursing ED, OR, ICU, floors Radiology Laboratory Blood bank Emergency medicine physician Anesthesiologist Orthopedic surgeon Neurosurgeon Risk management Standing Agenda Diversion Education Internal Education Outreach Education Injury Prevention Research Product Trials Statistics Disaster Preparedness Dashboard Policy Review Agenda Items

41 CORE STRATEGY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY QUALITY PEOPLE PEOPLE PEOPLE PEOPLE COST COST Mortality Rate Complication Rate Composite Nonsurgical Admission Under Triage Over Triage C-Spine Clearance doc < 48 hrs Readmission to ICU Readmission to Hospital Attending Surgeon Response EMS Run Sheets Present Grading of Solid Organ Injuries Average Minutes in ED for Activations Average Minutes in ED for Non-Activations Average Time to OR for Unstable Penetrating Trauma Nutrition Initiated within 48 hours DVT Prophylaxsis Registry Validity (error rating) Trauma Nursing Education Compliance Physician CME Compliance Peer Review Attendance Number of Peer Reviewed Publications ICU Length of Stay Hospital Length of Stay DASHBOARD Freq Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q BA A A BA A Q Q Q CY09 Q CY09 Q CY09 Q3 CY 09 Q4 Target/ Comparative NTDB 09 < 4.1% Historic < 7.1% ACS < 10% ACS < 5% ACS < 50% Historic > 97% Historic < 4% Historic < 2.3% ACS > 80% Historic > 78 % Historic > 64 % Historic < 122 mins Historic < 388 mins Historic < 18 min Historic >93 % < 1 100% 100% ACS > 50% ACS 7 ACS Historic < 5.5 Historic < 6.3 Historic < 6.2 Measures Peer Review Mortality and Morbidity conference To evaluate appropriateness of care Compliance with guidelines for care Evaluation of performance Systems Include subspecialties and all trauma surgeons Physicians Trauma Surgeons Burn Surgeons Anesthesia Lab/Pathology Radiology ED Ortho surgeon Neuro surgeon Nursing? Peer Review Prefer stand alone meeting Define criteria All deaths ED deaths DOA S Chart review Systems issues Repeat the PI issues & ask for discussion & determination EXAMPLE Patient Peer Review PI Filters: Trauma attending arrival time Unplanned return to OR ICU readmission Increased ICU LOS Multiple complications Death EXAMPLE Patient Peer Review MR # / Trauma # Date of admit: Date of discharge: ISS: 25, TRISS: MOI: Assault GSW to left sixth intercostal space, axillary line Incident time: ~

42 Pre-hospital provider Scene time: 8 minutes Pt found lying in fetal position on sidewalk VS: 120/88, HR 110, RR 22, SpO2 98% on 15 liters NRB, GCS 15 Interventions: Standard immobilization IV access 16 gage x2 IVF: 1300 ml of NS Decreased breath sounds on left Attempted chest decompression-w/o success 2218: Type 1 Trauma Team Activation 2220: Arrived at KUH ED VS: BP 135/85, ST 107, RR 20, SpO2 100% Temp 36.2, GCS : RSI 2238: Trauma Attending arrival -18 minutes 2240: Left chest tube placed Abdomen distended BP steadily dropping Plain films (next slides) 2246: BP 83/47, SR 98 HGB 10.6, HCT : Transported to OR Total fluids in ED: 2.6 liters NS En route to OR pt vomited Emergent exploratory laparotomy (1) Findings: ~ 1 liter of blood, peritoneal cavity Lacerations, left & right diaphragm Through & through stomach laceration Gross spillage of stomach contents Through & through liver laceration Procedures: Repair of lacerations Right thoracostomy tube placed, 400 ml bloody drainage Abdominal Wound VAC placed Intra-op: 3 units of PRBC's 6500mL IVF's 750ml of cell saver 2.5 liters EBL PTD #1 Post op VS: Temp 34.8, 118/66, SpO %, rate 14 on mechanical vent 0140: Admitted to SICU PTD #2 OR: Reexploration of abdomen (2) Procedures: Repair of previous gastrotomy Closure of abdomen EBL < 50 ml PTD #4 Transferred to floor PTD #5 Left plural effusion, drain placed OR, Re-exploration exploration to look for any other areas of obvious bleeding (4) Findings: Oozing from all surfaces Procedures: Perc tracheoatomy Ex lap Evacuation of hematoma Packing repair of liver laceration Partial fascial closure Wound VAC placement EBL: 1 liter

43 PTD # Palliative Care Consult Establish goals of care Withdraw of care - death Consults ID Nephrology Palliative Care Hepatology Endocrinology Adult Psych Neuropsychologist Wound/Ostomy ICU days: 51 Vent days: 43 Discussion & Determination Trauma Attending response time for type 1 Unplanned return to OR ICU readmission Increased ICU LOS Multiple complications Respiratory failure Renal failure Hepatic failure VAP UTI Multiple abdominal fistulas Death Peer Review Judgment & Determination Preventability or Acceptability Death & Complications Preventable Potentially Preventable Non-preventable Other Issues Acceptable Acceptable with reservations Unacceptable Peer Review Judgment & Determination Related Issues Systems Disease Provider Decisions should also include Error in judgment Delay in diagnosis Delay in treatment Patient disease (cause) Error in management Action Closed No further action Trend Guideline/Protocol/Pathway Education/Conference Communication Counseling Change in privileges/credentialing Refer for external review

44 Aggregate data Reports VAP UTI ED Documentation Specific Folder Data reports Education Correspondence P & P changes Trending Physician Response Time Physician Response Time N A B C D E UNK QRT 1 CY % 90% 64% 91% 18% QRT 2 CY % 80% 93% 86% 100% 26% QRT 3 CY % 88% 93% 100% 4% QRT 4 CY % 100% 68% 92% 15% QRT 1 CY % 75% 100% 24% QRT 2 CY % 85% 100% 16% TRAUMA COMPLICATIONS DRILL DOWN Measures Freq CY0 9 Q1 CY0 9 Q2 CY0 9 Q3 CY 09 Q4 Target/ Comparati ve Historic 08 Total Complication Rate Q % NTDB 09 Pneumonia Q % PE Q % ARDS Q % Decub Q % Sepsis Q % DVT Q % No Data for Reporting Period At or Better Than Target Future Measure Area of Concern Not Meeting Target Integration into Trauma Data Base

45 It is not about the data..it is what you do about the data.

46 Loop Closure Holy Grail of Qualitology Problem found Make changes Monitor change Adopt the outcome Document outcome Implementing PI Findings Usefulness Equation Usefulness = Relevance x Validity Work Implementing PI Findings Practice management guidelines Policy Procedures Care maps Protocols Why? Standardization Lowers error rate Makes evaluation of care easier Decreases cost (initially cost goes up long term costs go down Systematic Safe PI Does Not Have To Be Like This Take Home Points There is no perfect system Develop your PI program to meet the needs of your facility Make your data work for you Makes your job easier Systematic, standardized & safe Choose to be excellent Excellence is not a matter of chance, it s a matter of choice It's good for the patient

47 Resources afety_reference_manual

48 59-year-old male Trauma Case Study Michael Moncure, MD, FACS Medical Director, Level 1 Trauma Center The University of Kansas Hospital November 6, 2009 MOI: Fall Fell ~20 feet off scaffolding Landed on concrete ISS: 36 TRISS: : Ground EMS on scene Scene time: 14 minutes Pt found on his knees, bleeding from nose VS: BP 137/82, HR 67, RR 14, SpO2 94% on RA GCS 14 (4/4/6) Interventions O2 per NRB 10 liters per minute Peripheral IV access (total NS 100 ml) Full spinal immobilization 1820: Ground EMS arrival, ED local hospital BP 126/83, RR 18, SpO2 93% on RA GCS 15, PERRL - 2 mm Skin cool & clammy, feeling anxious 3 Unknown PMH Full trauma work-up Labs, Plain films, CT scans w/ contrast except to CT head Injuries identified per radiographic studies: Parietal & temporal skull factures SDH Right-sided hemopneumothorax Pulmonary contusion Multiple rib fractures 1843: Decision to transport to level 1 trauma center 1858: RSI : Ground EMS arrival at local hospital 1931: Departure to level 1 center BP 125/84, HR 64, GCS 3T Total Fluids PTA NS, 2 liters 1954: Type 1 trauma team activation 2010: Arrival at KUH ED, Trauma Bay BP 119/80, SR 84, SpO2 100%, Temp 35.2 GCS 3T, PERRL - 6mm : Propofol gtt,, 30 mcg/kg/min Plain films Warm blankets, warming lights & warmed fluids 2018: FAST negative 2019: Unable to place foley catheter Urology Consulted 2026: Right thoracostomy,, bloody output 2035: Transported to CT scanner 2110: Propofol gtt stopped d/t hypotension 6 1

49 2140: Transported to SICU Total fluids thus far: 2 liters NS, PTA 2 liters NS, Trauma Bay Radiographic Studies, injuries identified SAH/SDH IPH Extra-axial axial hematomas w/ contrecoup injury Right calvarial depressed fracture Right sphenoid sinus depressed fx, Right carotid canal depressed fx 7 Right orbital fracture Longitudinal & transverse fractures, bilateral temporal bones Right TP fractures, C6, C7, T1 Right intercostal artery laceration Large hemothorax,, right Right-sided rib fractures, 1 st to 10 Right pulmonary contusion Right adrenal hemorrhage Grade 1 liver laceration Labs, abnormal only ph 7.30 pco2 59 po2 28 BE 1.0 WBC HGB HCT Sodium 134 Anion gap 6 Glucose 191 Calcium

50 Urology Consult Flexible cystoscopy Large urethral false passage Council tip catheter placed Urethral injury, past trauma Neurosurgery Consult History per wife: MVC 20 years ago Right craniotomy for bleed Portion of brain removed 13 Neurosurgery exam: GCS 7T Overbreathing vent PERRL + Corneals + Cough + Gag No eye opening Localizes bilateral UE, R more brisk than L Withdraws bilateral LE Spontaneous nonpurposeful movments w/ all 4 extremities Plan bolt placement-icp monitoring, start Unasyn 14 ENT Consult Right temporal bone fracture, spares the otic capsule Blood, right auditory canal Ciprodex drops, right ear BID Right non displaced lateral orbital fracture, & right orbital roof fracture No surgical intervention minimally displaced fractures & no signs of entrapment Audiogram & facial nerve evaluation once extubated & stable 15 Admitted to SICU Temp 37.1, BP 159/71, SR 82 Renal protection protocol Art-line, PA catheter placement PA 23/11 Bolt placed by Neurosurgery Initial ICP 10 2 units PRBCs PTD #1 0020: Interventional Radiology Intercostal embolization Artic Sun to keep temp Post bolt 6 hours from initial CT 2 units RBCs Levophed gtt,, support of CPP ICP mid 20s ICP decreased w/ increased sedation Ophthalmology Consult Right orbital fracture EOM w/o restriction to forced ductions Chemosis OU without lagophthalmos Puralube while intubated PTD #2 ICP range CPP range Pt alert off sedation

51 Bolt removed per Neurosurgery Artic Sun stopped, temp in range Levophed gtt stopped PTD #3 CT head stable Opens eyes to stim & voice Follows commands BUE Pupils equal round & reactive to light Spont moves BLE PTD #3 PTD #2 Evolution of hemorrhages PTD #3 Vent weaning Cardiology Consult, SVT ECG: NSR w/o infarctions, injury or ischemia Telemetry: normal w/ runs atrial tachycardia at rates up to 180 bpm Amiodarone therapy PTD #4 Epidural catheter placement PCEA Extubated PTD #6 OR, Thoracotomy,, removed blood in chest Right chest tubes placed Rehab medicine consult PTD #7 CT head - stable Lethargic but arousable Does not move left side Localizes RUE, spontaneously moves RLE PTD #7 PTD #9 Pyrexia Diflucan, Flagyl, Zosyn IVC filter placed Positive urine culture, E. coli Levaquin PTD #10 Chest tubes to water seal PTD #11 Transferred to general surgery floor bed

52 PTD #13 Chest tubes discontinued PTD #14 Discharged to in-patient rehab RLA

53 Patrick T. Blatchford, MD General Surgeon South Central Kansas Regional Medical Center ABC s FAST Exam Small Problem or Big Trouble? OR vs CT vs Transfer ED ASSESSMENT HEPATORENAL SPACE ( POUCH OF MORRISSON) SPLENORENAL SPACE PERICARDIAL WINDOW PELVIS CHEST

54 ABCs Recognition of surgicaly correctable injuries 2 Liters of LR or NS Responder, Non responder, Transient responder Type and Cross Start uncross matched blood if non responsive or suspect ongoing blood loss Anticipate massive transfusion early based on injury Know ahead of time your facilities transfusion 24 y/o male with GSW x 5 to extremities, abdomen, and chest with unstable vital signs Airway (intubated in ED) #1. GSW to Lt Chest #2. GSW to Rt upper flank #3. GSW to Groin #4. GSW to buttocks #5. GSW to Left arm Hypotensive, tachycardic, non responder. Marked bullet wounds with paperclips and obtained plain films Positive FAST Uncrossmatched blood started 25 minutes from ED door to cut. Massive Hemoperitoneum >3 liters GSW thru Right lobe of the liver GSW thru hepatic flexure of the colon GSW thru small intestine x 6 Non-expanding hematoma of right sided retroperitoneum behind duodenum SMV and Middle colic vein injury

55 Ongoing Resuscitation of Patient as damage control was being performed Packing and repair of above described injuries Return to ICU Further Transfusion and resuscitation, and warming Follow lactic acidosis and correct accordingly ICU resucitation initially successful, however after 4 hr pt began to become tachycardic and vac output began to increase. Back to OR next morning because of rebleeding lactic acidosis and further blood loss. Mesenteric venous tributaries bleeding. Once Patient was warm and hemodynamically stable, was transferred to level 1 trauma center for ongoing ICU care

56 Questions?

57 Case Study Statewide Executive Meeting Wichita, KS November 6 th, 2009 Dr. Sonya Culver Pre-Hospital Information 18 yr old Male Motorcycle vs trash dumpster - Known rate of speed Blunt/penetrating trauma left upper chest: Flail Chest Exposed cardiac and pulmonary tissue 5-6 circumferential Fx Left Tib/Fib open Head: Laceration midline R forehead Tracheal Deviation to right; Paradoxical movement of flail segment EBL: ml Medflight Dispatched w/ 25 minute ETA. Scene time: 16 minutes Pre-Hospital Treatment Prehospital Treatment cont. Open Sucking chest wound covered by PD officer w/ clear zip lock bag prior to EMS arrival taped on 3 sides. Estimate injury time: 22:39 22:44 ACLS Assessment 22:46 18 G w/ NS R AC w/o 22:47 18 G w/ NS L AC w/o 22:48 Cardiac Monitor: NSR 22:49 BP127/99, P 67 strong, regular, R 32 shallow, irregular, O2 sat 94% RA Cap Refill: WNL 22:50 Spinal Immobilization 22:52 O2 15 L NRB 22:53 Etomidate 0.3 mg/kg IV 22:54 SUCCS RSI 22:55 Intubation attempt unsuccessful 22:57 Intubation successful w/ Sellicks maneuver. Visualization of cords. 7.0 ET tube 26 cm at teeth, Pos color change Co2 monitor. Equal BS ausculated, absent epigastric sounds. 23:02 Pt report Priority I trauma patient to Labette Health. ER Course ER Course Cont. 22:54 Trauma Alert called 23:09 Time of Arrival (All Trauma team present PTA) 23:10 NO Temp, BP 187/115, P 90, R 8-10 assisted, O2 sat 100%, Pain 0, GCS 3 intubated. Labs Drawn 23:11 Bp 200/109, P 98, R 8, O2 100%, Pupils 3 mm equal, GCS 3 23:13 Foley inserted. L tib/fib Fx reduced by Trauma Surgeon and ERP. Irrigated with NS and covered with NS soaked ABD and Kerlix. 23:15 Medflight crew at bedside. 23:18 Versed 2 mg IV. ERP reports abdomen firm 23:20 Norcuron 10mg IV. EMS infusion complete (2000 ml). 3 rd L NS started 23:28 Transfer to St John s via Medflight 1

58 Lab s Diagnosis HGB: 14.3 Glucose: 146 HCT: 41.2 AST: 44 WBC: 12.2 Calcium: 6.9 LC ABG ETOH: 245 PH: 7.34 Cannabinoids: Pos (+) PCO2: 38 HCO3: 20 ISS: 26 TRISS: Open Sucking Chest Wound w/ Flail Chest Left open compound Tib/Fib fracture open knee to ankle. CHI w/ scalp 4 cm laceration 2

59 REVISIONS Dennis Allin MD, FACEP Vice chair, ACT Incorporated: 2007 ACT reccommendations Specific action plans Education Field triage Communication between hospitals Review EMSystem for diversion issue Identify legislative liaison 2008 BIS Assessment SYSTEM ACCESS Enhanced 911 capacity First Responders Who are they They need medical direction COMMUNICATIONS Support for BEMS data EMS data system Reporting of response and scene times Benchmarks for response and scene times EMS response time Urban 10min Suburban 12 min Rural/Frontier 30 min Interfacility transfer 6 hrs EMS scene time 10 min COMMUNICATIONS BIS There are established procedures for EMS and trauma system communications in an all hazards or major EMS incident that are effectively coordinated with the overall all hazards response plan for the jurisdiction FIELD TRIAGE GUIDELINES Support of 100% EMResource Support of EMS Medical Director education Support of Trauma Medical directors State and Regional hospital transfer cards Development of over and undertriage criteria Field triage and transport guidelines All regions call for 2006 guidelines NE region has 1999 guidelines in appendix