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Trauma Systems Development: Trauma Systems Development: An ACS PerspectiveAn ACS PerspectiveTrauma Systems Development: Trauma Systems Development: An ACS PerspectiveAn ACS Perspective
Robert C. Mackersie, M.D., FACSRobert C. Mackersie, M.D., FACS
Professor of Surgery, UCSFProfessor of Surgery, UCSF
Director, Trauma Services, SFGHDirector, Trauma Services, SFGH
Past Chair, ACS-COT Trauma Past Chair, ACS-COT Trauma Systems Planning & EvaluationSystems Planning & Evaluation
Robert C. Mackersie, M.D., FACSRobert C. Mackersie, M.D., FACS
Professor of Surgery, UCSFProfessor of Surgery, UCSF
Director, Trauma Services, SFGHDirector, Trauma Services, SFGH
Past Chair, ACS-COT Trauma Past Chair, ACS-COT Trauma Systems Planning & EvaluationSystems Planning & Evaluation
California Trauma System Summit - 2008California Trauma System Summit - 2008California Trauma System Summit - 2008California Trauma System Summit - 2008
523,780 patients 18 states
J.Trauma 2004
523,780 patients 18 states
J.Trauma 2004
26.7
17.3
56
41.5
22
36.5
0
10
20
30
40
50
60
%
ALL TRAUMA MAJOR TRAUMA
LEVEL 1
LEVEL 2
NTC
26.7
17.3
56
41.5
22
36.5
0
10
20
30
40
50
60
%
ALL TRAUMA MAJOR TRAUMA
LEVEL 1
LEVEL 2
NTC
56
44
68.1
31.9
39.7
60.3
44
56
0
10
20
30
40
50
60
70
%
All pts deaths age >55 TBI > 55
Trauma Center Non- TC
56
44
68.1
31.9
39.7
60.3
44
56
0
10
20
30
40
50
60
70
%
All pts deaths age >55 TBI > 55
Trauma Center Non- TC
360,743 patients - California
JACS 2003
360,743 patients - California
JACS 2003
American College of Surgeons
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
facs.org facs.org facs.org facs.org
American College of Surgeons
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
LeadershipLeadership System DevelopmentSystem Development LegislationLegislation FinancesFinances Injury Prevention & ControlInjury Prevention & Control Human ResourcesHuman Resources
workforce / educationworkforce / education
LeadershipLeadership System DevelopmentSystem Development LegislationLegislation FinancesFinances Injury Prevention & ControlInjury Prevention & Control Human ResourcesHuman Resources
workforce / educationworkforce / education PrehospitalPrehospital
EMS, transport, EMS, transport, communication, disastercommunication, disaster
Definitive CareDefinitive Care TCs, transfers, rehabTCs, transfers, rehab
Information systemsInformation systems EvaluationEvaluation Research Research
PrehospitalPrehospital EMS, transport, EMS, transport,
communication, disastercommunication, disaster Definitive CareDefinitive Care
TCs, transfers, rehabTCs, transfers, rehab Information systemsInformation systems EvaluationEvaluation Research Research
1992 MTCSP: What a system 1992 MTCSP: What a system IS.IS.
1992 MTCSP: What a system 1992 MTCSP: What a system IS.IS.
2006 Model Trauma System Planning and Evaluation:2006 Model Trauma System Planning and Evaluation:
What a system DOES.What a system DOES.
2006 Model Trauma System Planning and Evaluation:2006 Model Trauma System Planning and Evaluation:
What a system DOES.What a system DOES.
AssessmentAssessment systems needs vrs. resourcessystems needs vrs. resources injury epidemiologyinjury epidemiology ‘ ‘burden of injury’ & system performanceburden of injury’ & system performance cost effectiveness cost effectiveness
Policy DevelopmentPolicy Development Comprehensive authorityComprehensive authority Trauma Plan & modificationsTrauma Plan & modifications Prevention public policyPrevention public policy Establishes evidence-based system guidelinesEstablishes evidence-based system guidelines Is driven by assessmentIs driven by assessment
AssuranceAssurance Use of laws, regulations, standardsUse of laws, regulations, standards System PI & oversight bodySystem PI & oversight body Integration of primary, secondary, tertiary Integration of primary, secondary, tertiary
preventionprevention Strategic planning (workforce, all-hazards Strategic planning (workforce, all-hazards
preparedness, etc) preparedness, etc)
AssessmentAssessment systems needs vrs. resourcessystems needs vrs. resources injury epidemiologyinjury epidemiology ‘ ‘burden of injury’ & system performanceburden of injury’ & system performance cost effectiveness cost effectiveness
Policy DevelopmentPolicy Development Comprehensive authorityComprehensive authority Trauma Plan & modificationsTrauma Plan & modifications Prevention public policyPrevention public policy Establishes evidence-based system guidelinesEstablishes evidence-based system guidelines Is driven by assessmentIs driven by assessment
AssuranceAssurance Use of laws, regulations, standardsUse of laws, regulations, standards System PI & oversight bodySystem PI & oversight body Integration of primary, secondary, tertiary Integration of primary, secondary, tertiary
preventionprevention Strategic planning (workforce, all-hazards Strategic planning (workforce, all-hazards
preparedness, etc) preparedness, etc)
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
American College of Surgeons
COMMITTEE ON TRAUMA Consultation Program for Trauma Systems
ACS-COT Trauma Systems EvaluationACS-COT Trauma Systems EvaluationACS-COT Trauma Systems EvaluationACS-COT Trauma Systems Evaluation
Consultative, not verification (no one fails!) Multi-disciplinary structure Independently derived recommendations (ACS
integrity) Politically ‘inert’ Consensus-based process Basis = Inclusive trauma system (MTCSP) Basis = best interests of the patient Collaborative development:
(HRSA, NHTSA, CDC, NASEMSD, ACEP) based on national objectives (HRSA, NHTSA)
Consultative, not verification (no one fails!) Multi-disciplinary structure Independently derived recommendations (ACS
integrity) Politically ‘inert’ Consensus-based process Basis = Inclusive trauma system (MTCSP) Basis = best interests of the patient Collaborative development:
(HRSA, NHTSA, CDC, NASEMSD, ACEP) based on national objectives (HRSA, NHTSA)
Trauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common Problems
Reluctance to use enabling legislationReluctance to use enabling legislation Inconsistent or non-integrated leadershipInconsistent or non-integrated leadership Unauthorized leadershipUnauthorized leadership Absent or ineffective state (STACs) or Absent or ineffective state (STACs) or
regional advisory committees (RTCC)regional advisory committees (RTCC) Trends towards exclusive systemsTrends towards exclusive systems
no resources, commitment, interestno resources, commitment, interest lack of consistent specialty availabilitylack of consistent specialty availability over-triage, over-transfer to designated centersover-triage, over-transfer to designated centers
Reluctance to use enabling legislationReluctance to use enabling legislation Inconsistent or non-integrated leadershipInconsistent or non-integrated leadership Unauthorized leadershipUnauthorized leadership Absent or ineffective state (STACs) or Absent or ineffective state (STACs) or
regional advisory committees (RTCC)regional advisory committees (RTCC) Trends towards exclusive systemsTrends towards exclusive systems
no resources, commitment, interestno resources, commitment, interest lack of consistent specialty availabilitylack of consistent specialty availability over-triage, over-transfer to designated centersover-triage, over-transfer to designated centers
Trauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common Problems
Lack of funding: system & under-Lack of funding: system & under-compensated carecompensated care
No comprehensive trauma planNo comprehensive trauma plan Limited (or non-existent) system-based PILimited (or non-existent) system-based PI Limited regional organization & Limited regional organization & participation by NTC facilitiesparticipation by NTC facilities
Ends of the spectrum poorly integrated Ends of the spectrum poorly integrated (silo’ing) : prevention & rehabilitation in (silo’ing) : prevention & rehabilitation in particularparticular
Lack of funding: system & under-Lack of funding: system & under-compensated carecompensated care
No comprehensive trauma planNo comprehensive trauma plan Limited (or non-existent) system-based PILimited (or non-existent) system-based PI Limited regional organization & Limited regional organization & participation by NTC facilitiesparticipation by NTC facilities
Ends of the spectrum poorly integrated Ends of the spectrum poorly integrated (silo’ing) : prevention & rehabilitation in (silo’ing) : prevention & rehabilitation in particularparticular
Trauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common ProblemsTrauma Systems: Common Problems
Structure does not allow strong medical Structure does not allow strong medical direction for state/regional trauma sysdirection for state/regional trauma sys
Incomplete, inadequate MOU between Incomplete, inadequate MOU between sending & receiving hospitalssending & receiving hospitals
Limited, often inadequate public and Limited, often inadequate public and legislative education RE trauma system legislative education RE trauma system importance & needsimportance & needs
various others…various others…
Structure does not allow strong medical Structure does not allow strong medical direction for state/regional trauma sysdirection for state/regional trauma sys
Incomplete, inadequate MOU between Incomplete, inadequate MOU between sending & receiving hospitalssending & receiving hospitals
Limited, often inadequate public and Limited, often inadequate public and legislative education RE trauma system legislative education RE trauma system importance & needsimportance & needs
various others…various others…
Access: Obstacles in trauma system Access: Obstacles in trauma system participationparticipation
Access: Obstacles in trauma system Access: Obstacles in trauma system participationparticipation
Physician staff commitmentPhysician staff commitment Lifestyle: long, irregular hours, sleep deprivationLifestyle: long, irregular hours, sleep deprivation Practice: opportunity costs, restriction, reimbursement, Practice: opportunity costs, restriction, reimbursement,
malpractice malpractice Intimidating, verification / designation Intimidating, verification / designation
requirementsrequirements Lack of knowledge / experienceLack of knowledge / experience Financial risk: Financial risk:
Under-funded care, contractual agreementsUnder-funded care, contractual agreements Limited transfer $$: DSH, local tax subsidiesLimited transfer $$: DSH, local tax subsidies On-call fees for physiciansOn-call fees for physicians Lack of specific state/regional funding Lack of specific state/regional funding
Physician staff commitmentPhysician staff commitment Lifestyle: long, irregular hours, sleep deprivationLifestyle: long, irregular hours, sleep deprivation Practice: opportunity costs, restriction, reimbursement, Practice: opportunity costs, restriction, reimbursement,
malpractice malpractice Intimidating, verification / designation Intimidating, verification / designation
requirementsrequirements Lack of knowledge / experienceLack of knowledge / experience Financial risk: Financial risk:
Under-funded care, contractual agreementsUnder-funded care, contractual agreements Limited transfer $$: DSH, local tax subsidiesLimited transfer $$: DSH, local tax subsidies On-call fees for physiciansOn-call fees for physicians Lack of specific state/regional funding Lack of specific state/regional funding
California trauma “system”California trauma “system”California trauma “system”California trauma “system”
Serving disaster-prone, dispersed populationServing disaster-prone, dispersed population Provides coverage for very urban & very rural regionsProvides coverage for very urban & very rural regions County –based & de-centralizedCounty –based & de-centralized Optional – but embraced by most counties Optional – but embraced by most counties Relies on local versus regional/State-wide oversightRelies on local versus regional/State-wide oversight State & many local systems under-fundedState & many local systems under-funded State/regional structures insufficiently authorized State/regional structures insufficiently authorized Comprehensive, state-wide plan pendingComprehensive, state-wide plan pending Wide variations in county trauma system configurations & practices Wide variations in county trauma system configurations & practices
(“inconsistencies” (“inconsistencies” State-wide trauma registry pending State-wide trauma registry pending
Serving disaster-prone, dispersed populationServing disaster-prone, dispersed population Provides coverage for very urban & very rural regionsProvides coverage for very urban & very rural regions County –based & de-centralizedCounty –based & de-centralized Optional – but embraced by most counties Optional – but embraced by most counties Relies on local versus regional/State-wide oversightRelies on local versus regional/State-wide oversight State & many local systems under-fundedState & many local systems under-funded State/regional structures insufficiently authorized State/regional structures insufficiently authorized Comprehensive, state-wide plan pendingComprehensive, state-wide plan pending Wide variations in county trauma system configurations & practices Wide variations in county trauma system configurations & practices
(“inconsistencies” (“inconsistencies” State-wide trauma registry pending State-wide trauma registry pending
System developmentSystem developmentSystem developmentSystem development
Educate & build legislative & public supportEducate & build legislative & public support Establish enabling legislationEstablish enabling legislation Fund the system exclusive from TCsFund the system exclusive from TCs Needs assessment (link to prevention)Needs assessment (link to prevention) Write comprehensive trauma planWrite comprehensive trauma plan Adopt operational standards & verificationAdopt operational standards & verification Develop oversight structuresDevelop oversight structures Initiate system PI plan & oversightInitiate system PI plan & oversight System development driven by PI / CQISystem development driven by PI / CQI Perform external consultative reviewPerform external consultative review
Educate & build legislative & public supportEducate & build legislative & public support Establish enabling legislationEstablish enabling legislation Fund the system exclusive from TCsFund the system exclusive from TCs Needs assessment (link to prevention)Needs assessment (link to prevention) Write comprehensive trauma planWrite comprehensive trauma plan Adopt operational standards & verificationAdopt operational standards & verification Develop oversight structuresDevelop oversight structures Initiate system PI plan & oversightInitiate system PI plan & oversight System development driven by PI / CQISystem development driven by PI / CQI Perform external consultative reviewPerform external consultative review
““Get a plan” Get a plan” (G. Cooper, ~2004)(G. Cooper, ~2004) ““Get a plan” Get a plan” (G. Cooper, ~2004)(G. Cooper, ~2004)
System structure:System structure: lead agency, STAC, RTCCs, role of TCs & communitylead agency, STAC, RTCCs, role of TCs & community System leadership positions within structure (TMD, TPM)System leadership positions within structure (TMD, TPM) Regional structure: ‘X’ regions? (not 32 or 58) Regional structure: ‘X’ regions? (not 32 or 58)
System-wide needs assessmentSystem-wide needs assessment Injury epidemiology in the StateInjury epidemiology in the State Type, number, location of TCs & flow patternsType, number, location of TCs & flow patterns Human resource pipeline Human resource pipeline
System oversight responsibilities & PI planSystem oversight responsibilities & PI plan Disaster preparedness (current surge cap=~14%)\Disaster preparedness (current surge cap=~14%)\ Establish process/program for injury surveillance Establish process/program for injury surveillance
System structure:System structure: lead agency, STAC, RTCCs, role of TCs & communitylead agency, STAC, RTCCs, role of TCs & community System leadership positions within structure (TMD, TPM)System leadership positions within structure (TMD, TPM) Regional structure: ‘X’ regions? (not 32 or 58) Regional structure: ‘X’ regions? (not 32 or 58)
System-wide needs assessmentSystem-wide needs assessment Injury epidemiology in the StateInjury epidemiology in the State Type, number, location of TCs & flow patternsType, number, location of TCs & flow patterns Human resource pipeline Human resource pipeline
System oversight responsibilities & PI planSystem oversight responsibilities & PI plan Disaster preparedness (current surge cap=~14%)\Disaster preparedness (current surge cap=~14%)\ Establish process/program for injury surveillance Establish process/program for injury surveillance
Funding the system Funding the system Funding the system Funding the system
SYSTEM = STATE, REGIONAL, COUNTYSYSTEM = STATE, REGIONAL, COUNTY Motor vehicle fees, fines, penalties (non-MV also)Motor vehicle fees, fines, penalties (non-MV also) 911 system surcharges911 system surcharges Intoxication / DUI offense feesIntoxication / DUI offense fees Controlled substance act or weapons violation feesControlled substance act or weapons violation fees “ “Play or pay” fees for non-participating hospitalsPlay or pay” fees for non-participating hospitals Tobacco & ETOH taxesTobacco & ETOH taxes Property tax supplementsProperty tax supplements Tribal gamingTribal gaming Hospital licensure linked to participation in TSHospital licensure linked to participation in TS Use of destination / activation fees Use of destination / activation fees
SYSTEM = STATE, REGIONAL, COUNTYSYSTEM = STATE, REGIONAL, COUNTY Motor vehicle fees, fines, penalties (non-MV also)Motor vehicle fees, fines, penalties (non-MV also) 911 system surcharges911 system surcharges Intoxication / DUI offense feesIntoxication / DUI offense fees Controlled substance act or weapons violation feesControlled substance act or weapons violation fees “ “Play or pay” fees for non-participating hospitalsPlay or pay” fees for non-participating hospitals Tobacco & ETOH taxesTobacco & ETOH taxes Property tax supplementsProperty tax supplements Tribal gamingTribal gaming Hospital licensure linked to participation in TSHospital licensure linked to participation in TS Use of destination / activation fees Use of destination / activation fees
Oversight committees Oversight committees Oversight committees Oversight committees
Use experience of States with well established state-Use experience of States with well established state-wide trauma systems & organizationswide trauma systems & organizations
Expand the STACExpand the STAC Develop & fund positions for system oversight / Develop & fund positions for system oversight /
admin. admin. State Trauma Medical Director + State Program staff (SB261) State Trauma Medical Director + State Program staff (SB261) Regional program staff + admin staff (Romero SB261)Regional program staff + admin staff (Romero SB261)
Recruit system leadership (medicine, government, Recruit system leadership (medicine, government, business, law) business, law)
Using the TP, establish & authorize advisory cmtesUsing the TP, establish & authorize advisory cmtes Define role of RTCC relative to LEMSAs (“integrated”)Define role of RTCC relative to LEMSAs (“integrated”) Develop Develop systemsystem PI program tailored to regions PI program tailored to regions
Use experience of States with well established state-Use experience of States with well established state-wide trauma systems & organizationswide trauma systems & organizations
Expand the STACExpand the STAC Develop & fund positions for system oversight / Develop & fund positions for system oversight /
admin. admin. State Trauma Medical Director + State Program staff (SB261) State Trauma Medical Director + State Program staff (SB261) Regional program staff + admin staff (Romero SB261)Regional program staff + admin staff (Romero SB261)
Recruit system leadership (medicine, government, Recruit system leadership (medicine, government, business, law) business, law)
Using the TP, establish & authorize advisory cmtesUsing the TP, establish & authorize advisory cmtes Define role of RTCC relative to LEMSAs (“integrated”)Define role of RTCC relative to LEMSAs (“integrated”) Develop Develop systemsystem PI program tailored to regions PI program tailored to regions
Other key elements Other key elements Other key elements Other key elements
Acute care access: assess Acute care access: assess adequacy of existing TCs – level & adequacy of existing TCs – level & locationlocation
Assess adequacy of existing Assess adequacy of existing resources, county-by-countyresources, county-by-county
Cultivate participation in Cultivate participation in state/regional trauma systemstate/regional trauma system institutional & provider incentivesinstitutional & provider incentives
Accessible, state-wide registry Accessible, state-wide registry
Acute care access: assess Acute care access: assess adequacy of existing TCs – level & adequacy of existing TCs – level & locationlocation
Assess adequacy of existing Assess adequacy of existing resources, county-by-countyresources, county-by-county
Cultivate participation in Cultivate participation in state/regional trauma systemstate/regional trauma system institutional & provider incentivesinstitutional & provider incentives
Accessible, state-wide registry Accessible, state-wide registry
Getting started - Getting started - System-wide PI will drive System-wide PI will drive
developmentdevelopment
Getting started - Getting started - System-wide PI will drive System-wide PI will drive
developmentdevelopment
System-based (versus center-based) System-based (versus center-based) PIPI
System-based (versus center-based) System-based (versus center-based) PIPI
Old model designed for developing Old model designed for developing systemssystems
Relies more on shared center-derived PI Relies more on shared center-derived PI issues (MAC model)issues (MAC model)
Focus on provider vrs. system errorsFocus on provider vrs. system errors Limited use of system indicatorsLimited use of system indicators Limited focus on PI process effectivenessLimited focus on PI process effectiveness
Old model designed for developing Old model designed for developing systemssystems
Relies more on shared center-derived PI Relies more on shared center-derived PI issues (MAC model)issues (MAC model)
Focus on provider vrs. system errorsFocus on provider vrs. system errors Limited use of system indicatorsLimited use of system indicators Limited focus on PI process effectivenessLimited focus on PI process effectiveness
System-wide PI System-wide PI will drive will drive
developmentdevelopment
System-wide PI System-wide PI will drive will drive
developmentdevelopment
system preventable deathssystem preventable deaths access to trauma systemaccess to trauma system time to definitive caretime to definitive care triage errorstriage errors failed / delayed transfersfailed / delayed transfers provider errors (TAC/MAC)provider errors (TAC/MAC) access to rehabaccess to rehab prevention deficienciesprevention deficiencies benchmarking for TCsbenchmarking for TCs
system preventable deathssystem preventable deaths access to trauma systemaccess to trauma system time to definitive caretime to definitive care triage errorstriage errors failed / delayed transfersfailed / delayed transfers provider errors (TAC/MAC)provider errors (TAC/MAC) access to rehabaccess to rehab prevention deficienciesprevention deficiencies benchmarking for TCsbenchmarking for TCs
Adopt standards, analyze Adopt standards, analyze performanceperformance
Develop P&PsDevelop P&Ps transfers, re-triage, transfers, re-triage,
Create ‘operational’ Create ‘operational’ MOUs between centersMOUs between centers Educational ‘give-backs’Educational ‘give-backs’ PI driven outreachPI driven outreach
Link to state registry & Link to state registry & prevention activitiesprevention activities
ID & monitor outcome ID & monitor outcome measures & benchmarksmeasures & benchmarks
Adopt standards, analyze Adopt standards, analyze performanceperformance
Develop P&PsDevelop P&Ps transfers, re-triage, transfers, re-triage,
Create ‘operational’ Create ‘operational’ MOUs between centersMOUs between centers Educational ‘give-backs’Educational ‘give-backs’ PI driven outreachPI driven outreach
Link to state registry & Link to state registry & prevention activitiesprevention activities
ID & monitor outcome ID & monitor outcome measures & benchmarksmeasures & benchmarks
RTCC tasksRTCC tasksRTCC tasksRTCC tasks
World’s seventh largest economy: World’s seventh largest economy: we can do this.we can do this.
World’s seventh largest economy: World’s seventh largest economy: we can do this.we can do this.