Building Kentuckys Trauma System

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Building Kentuckys Trauma System

• Julia F. Costich, J.D., Director
• Kentucky Injury Prevention and Research Center

2
Definitions

• Trauma patient Seriously injured person at high
  risk for death or disability in the absence of
  timely diagnosis and treatment by a team of
  professionals supported by specialized resources
• Trauma center Hospital designated (verified)
  by the American College of Surgeons that has
  surgeons and other specialists committed to
  treating trauma patients

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Trauma system

• Organized, coordinated effort
• in a defined geographic area
• that delivers the full range of services
• to all trauma patients
• and is integrated with the public health system
  for injury prevention and surveillance
• Benefits
• Increase survival of seriously injured
• Reduce burden of trauma-related death and
  disability
• Improve efficiency of system components

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Example of system goals (MD)

• Monitor the states population-based occurrence
  of injury
• Assure integration and coordination of trauma
  system through effective partnerships
• Assure secure and adequate financing
• Monitor and track patient outcomes including
  death and disability as well as system
  performance
• Coordinate emergency and disaster preparedness
  with responsible state agencies

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Fundamental components

• Injury prevention and surveillance
• Community-based and within system
• Pre-hospital care
• Scene, EMS, emergency department
• Acute care
• Post-hospital care
• Outpatient follow-up, rehabilitation, secondary
  prevention

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Barriers to trauma system

• Competition among providers (EMS, hospitals)
• High cost of resources (surgeons, other hospital
  staff, imaging and other equipment)
• High proportion of patients with low-paying (or
  no) coverage
• Maldistribution of resources in relation to risk
  of injury (particularly rural areas)
• Inadequate attention to and funding for injury
  prevention and surveillance

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Trauma Center Verification Levels

• I Tertiary care center with leadership role in
  system development, care, education and research.
  UK, UL
• II Definitive care center, principal community
  hospital. None in Kentucky
• III Commitment to general trauma care,
  stabilizes major trauma patient for transfer, in
  community lacking Level I or II center. Russell
  County Hospital
• IV Initial care provider, stabilizes for
  transfer. None in Kentucky

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Trauma system development funding in Kentucky

• HRSA funding for plan development 1994
• Withdrawn in 1996
• State trauma plan never enacted
• Recurrent small (45K) grants in 2001,
• 2002-2005, 2006-?
• Entire program terminates in current version of
  2007 federal budget
• Issue how to fund trauma registry?

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Special problems in rural state

• Distance to definitive care
• Road conditions
• Lack of education
• Higher prevalence of poverty
• Lower quality of vehicles and safety devices
• Lower rate of seat belt use
• HIGHER RATE OF INJURY IN A CRASH

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Impact of trauma in Kentucky

• Unintentional injury is the leading cause of
  death for Kentuckians aged 1-34
• Motor vehicle crashes (57), falls (14) and
  suicides (9) are the three leading causes of
  major trauma in Kentucky

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CINCINNATI
TRAUMA CENTERS SERVING KENTUCKY
HUNTINGTON
TC
TC
TC
KNOXVILLE
VANDERBILT
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The Golden Hour
Early trauma deaths can be impacted by rapid
evaluation and resuscitation
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Motor Vehicle Crash Fatality Rate,
1998-2002 Source Kentucky Transportation Center
Crash Analysis, Table 7
Fatalities per 100 million miles traveled state
mean1.6
1.0 and under
1.0-1.5
1.6-2.5
Campbell
Boone
Kenton
Over 2.5
Gallatin
Bracken
Pendleton
Carrll
Grant
Mason
Trimble
Owen
Greenup
Robertson
Lewis
Henry
Harrison
Oldham
Fleming
Nicholas
Boyd
Carter
Scott
Franklin
Jefferson
Rowan
Shelby
Bourbon
Bath
Elliott
Lawrence
Fayette
Woodford
Montgomery
Spencer
Anderson
Bullitt
Meade
Menifee
Clark
Jessamine
Morgan
Johnson
Powell
Mercer
Hancock
Nelson
Martin
Breckinridge
Henderson
Madison
Daviess
Estill
Magoffin
Wolfe
Washington
Hardin
Garrard
Boyle
Union
Lee
Larue
Webster
Mclean
Marion
Breathitt
Floyd
Lincoln
Jackson
Ohio
Pike
Grayson
Owsley
Rockcastle
Crittenden
Taylor
Knott
Casey
Hart
Hopkins
Perry
Edmonson
Green
Muhlenberg
Clay
Livingston
Caldwell
Laurel
Pulaski
Leslie
Letcher
Adair
Ballard
Mccracken
Metcalfe
Lyon
Russell
Barren
Warren
Carlisle
Marshall
Christian
Knox
Harlan
Logan
Cumberland
Todd
Trigg
Wayne
Simpson
Allen
Graves
Bell
Whitley
Clinton
Hickman
Mccreary
Monroe
Calloway
Fulton
Prepared by Julia F. Costich, Kentucky Injury
Prevention Research Center

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Trauma system assessment benchmarks (HRSA 2006)

• Thorough description of the jurisdictions injury
  epidemiology
• N.b. unintentional injury is leading cause of
  death in Kentuckians ages 1-34
• Established trauma management information system
  for surveillance and system performance assessment

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Trauma system assessment benchmarks (HRSA 2006)

• System resource assessment completed and
  regularly updated
• Emergency preparedness assessment completed and
  coordinated with emer-gency management agency,
  PH, EMS
• System assesses and monitors its value,
  cost-benefit, societal investment

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Policy benchmarks

• Comprehensive state statutory authority and
  administrative rules for trauma system
  infrastructure, planning, oversight, and future
  development.
• Collaborative evaluation including governmental,
  medical, professional, citizen organizations.

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Policy benchmarks (HRSA 2006)

• Comprehensive written trauma system plan
• Developed in collaboration with community
  partners and stakeholders
• Integrates trauma system with EMS, public health,
  emergency preparedness, and incident management.
• Trauma, public health, emergency preparedness
  systems closely linked

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Policy benchmarks

• Sufficient resources, including those both
  financial and infrastructure related, support
  system planning, implementation, and maintenance
• Data collected and used to evaluate system
  performance and develop public policy

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Policy benchmarks

• Lead agency informs state, regional, local
  constituencies and policy makers to foster
  cooperation for system enhancement and injury
  control
• Nature and identification of lead agency critical
  to entire development process

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Assurance benchmarks (HRSA 2006)

• Management information system for ongoing
  assessment of performance, including cost-benefit
• Support of EMS system including
• communications,
• medical oversight,
• prehospital triage,
• transportation
• well-integrated trauma system, EMS system, public
  health agency

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Assurance benchmarks

• Efficient, inclusive acute care network
• Lead agency monitors system performance and
  prevention effectiveness in cooperation with
  other stakeholders
• Lead agency
• ensures that trauma system plan is integrated
  with and
• complements comprehensive mass casualty plan for
  both natural and manmade incidents (all hazards
  approach)

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Assurance benchmarks

• Lead agency ensures that trauma system
  demonstrates prevention and medical outreach
  activities within its defined service area
• Each hospital works to improve trauma care as
  measured by patient outcomes to maintain its
  state, regional, or local designation.

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Assurance benchmarks

• Lead agency ensures adequate rehabilitation
  facilities have been integrated into trauma
  system and made available to all populations
  requiring them
• Financial aspects integrated into overall
  performance improvement system for fine-tuning
  and cost-effectiveness

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Assurance benchmarks

• Lead agency ensures competent workforce
• Lead agency protects public welfare by enforcing
  relevant laws, rules, regulations
• Assumes lead agency has enforcement powers!

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Stakeholder conferences

• November 11-13, 2001
• June 25-26, 2003
• June 23, 2004
• January 23-24, 2005
• March 7-8, 2006

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KENTUCKY
KENTUCKY EMSC FUNDED CONTINUOUSLY SINCE
1996 EDUCATION PARTNERSHIP
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Definitive care pediatric facilities

• All emergency departments should be capable of
  providing stabilization to injured children
• Trained staff
• Pediatric equipment
• Separate area
• Family-centered support
• Communication linkages
• Transport agreements

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SWOT analysis strengths

• Good coverage for air medical scene response
• Quality and commitment of EMS, RNs, MDs
• De facto trauma system in urban areas
• KIPRC resources for data analysis

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SWOT analysis weaknesses

• Missing EMS, Emergency Department data
• Poor understanding of trauma system by state
  residents (survey)
• Lack of funding for true system development
• HRSA funding ceases in 2007
• MDs increasingly unwilling to care for trauma
  patients and take ED call (particularly surgeons)
• Low socioeconomic status of much of state

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SWOT analysis opportunities

• KBEMS
• Building on infrastructure for disaster
  preparedness and response
• Potential for regionalization of services
• Statewide initiative to build epidemiological
  capacity

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SWOT analysis threats

• Shortages of all health care providers in rural
  areas
• Mid-size hospitals lack resources for trauma
  care, verification
• Reimbursement, professional liability
• County political boundaries for EMS coverage
• Discoverability of quality assurance materials in
  litigation

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Kentucky Hosp. Assn Survey

• ED Physician Certification
• 74 ACLS, 37 ATLS, 46 PALS
• 46 require board certification or eligibility
• Major Problems with Trauma Care
• 64 cited lack of specialists
• 36 cited delays in transport to other facilities
  due to terrain or weather
• 31 cited lack of knowledge of doctors, nurses
  and EMS for trauma care
• 15 cited uncompensated care

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Support for Kentucky trauma care

• Representative sample of 800 Kentuckians surveyed
  by phone in 2005 (117 counties)
• Over 78 stated unequivocal support for trauma
  care funding
• Four of five respondents supported assessments on
  traffic fines
• Four of five respondents supported trauma system
  legislation
• Complete report in December 2005 KMA Journal

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Funding options for trauma care

• Motor vehicle fees and fines (DUI, speeding)
• Auto insurance or registration surcharge (not as
  popular)
• Cigarette tax
• Lottery revenues

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Why funding is needed

• Health professional education
• Assist facilities with cost of achieving
  verification status
• Injury prevention initiatives
• State trauma coordinator
• Maintenance of trauma registry and related
  research
• Support for unfunded care and transfers
• Continued support for stakeholder meetings

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Next steps

• Implementing legislation
• Including dedicated funding source
• Assistance to facilities for voluntary
  participation
• Estimated 40-60,000 for initial status plus
  ongoing costs
• Serious need for broader accessibility
• Consensus on triage protocols, EMS coordination,
  resource allocation
• Very difficult in all states that have addressed
  issues

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Discussion topics

• Missing elements
• Prioritization and sequencing
• Identification of lead agency
• Obstacles/challenges
• Communicating with policymakers to develop
  successful legislative initiative

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