American College of Surgeons view on the California Trauma System James W. Davis MD, FACS Professor of Clinical Surgery UCSF/Fresno

The ACS View of California Trauma System A few disclaimers…. Conference call with –John Fildes MD, COT Chair –Wayne Meredith MD, director ACS Trauma programs –Mike Rotondo MD, Chair Systems Committee Sent powerpoint presentations (shamelessly borrowed)

Some more disclaimers…. There are real ACS COT experts present Past COT Chairs –A. Brent Eastman MD –David B. Hoyt MD COT Vice Chair –Margaret M. Knudson MD Last year’s speaker –Robert C. Mackersie MD

Trauma Systems Development: An ACS Perspective Robert C. Mackersie, M.D., FACS Professor of Surgery, UCSF Director, Trauma Services, SFGH Past Chair, ACS-COT Trauma Systems Planning & Evaluation Robert C. Mackersie, M.D., FACS Professor of Surgery, UCSF Director, Trauma Services, SFGH Past Chair, ACS-COT Trauma Systems Planning & Evaluation California Trauma System Summit

ACS View Why develop trauma systems? Trauma Systems save lives –San Diego: decreased preventable deaths from 14% to 3% J Trauma Sep;26(9): –Oregon: 18% reduction in mortality J Trauma 1998; 44(4): –Florida: 15% reduction in mortality J Trauma 2006; 60(2):

Mortality Reduction: 25% Lower in TC In Hospital 30 d 90 d365 d TCs NTCs NEJM 2006;354:366-78

Trauma System Development Overall survival: (Nathens – 2000) – improved MVC Survival: (Nathens – 2000) – improved Geriatric Survival: (Mann – 2001) – improved Remote Rural Survival: (Mann – 2001) –Improved Process of care (Olson – 2001) Process of care (Olson – 2001) – improved … only a sample of the studies …

Disparities in Access by Rurality % of Population Living Within 45 minutes of a I/II Trauma Center Urban89% Suburban73% Rural8% Branas, MacKenzie et al, JAMA, 2005

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

What do we do for the rurally injured patient? We cannot just shoot ‘em We need a REAL state- wide trauma system

ACS Systems Assessment: regular and systematic collection and analysis of data to determine status and need for intervention Policy Development: establish comprehensive policies to improve health Assurance: goals to improve the public’s health by providing regulated services

“ACS Perspective” ACS Regional Trauma Systems: Optimal Elements, Integration and Assessment –Copyright 2008, ACS State of California State Trauma System Implementation: A Discussion Draft –March 6, 2008 Standards (optimal elements), and State assessments placed in tables –Benchmark Indicator Scores (BIS)

System Assessment ACSCalifornia Injury EpidemiologyThorough description of epidemiology of injury Score: 3-5, not statewide data, not linked Trauma Management Information System Established trauma MISScore: 1 - NO Resource AssessmentAssessment completed and updated Score: 1-3; gap analysis and preventability Emergency Preparedness Assessment Assessment completed including Coordination Score: 1-4 no gap analysis Cost/Benefit and Societal Investment Assesses and monitors values to constituents Score: 1-2 No data available to document

Policy Development ACSCalifornia Statutory Authority/ Administrative Rules Statutory Authority & Administrative rules Score: 3-4, BUT legislative authority for all components – lacking System LeadershipProcess used to establish, maintain, improve system Score: 1-5, No clearly defined structure for system decision making process, no goals or objectives Statewide Trauma System, Plan Comprehensive written system plan Score: 2-3, no statewide plan, no evidence to demonstrate an integrated disaster and trauma system Financial & Infrastructure related resources Sufficient resources exist, financial and infrastructure Score: 1-3, no method of assessing resources, no commitment of funds for services, no resources for mass casualty

Policy Development ACSCalifornia System Performance Data Data used to evaluate performance and develop policy Score: 1-4, varying databases, no reporting structure, no system performance standards, no trauma MIS Performance Reports and Reviews System leaders review system performance reports Score: 1-2, no trauma data reports, statewide TAC does not review data reports Inform/Educate Partnerships Lead agency informs and educates State, fosters collaboration Score: 1-3, no public information & education plan Public Health Emergency Preparedness Links Trauma, public health and emergency preparedness are linked Score: 2-3, little surveillance shared with trauma and program linkage is occurring

System Assurance ACSCalifornia Trauma MIS & Outcomes Trauma MIS used to facilitate assessment & assurance of system performance Score: 2-3, TC’s have registry, but no state- wide trauma registry EMS System SupportSystem supported by EMS, trauma, EMS, public health integrated Score: 2-5; differences in triage criteria, EMS oversight local, no system wide procedure for transfers Role for all Acute Care Facilities All acute care facilities integrated into network that meets standards & provides optimal care for all injured patients Score: 1-4; no plan that outlines roles and responsibilities of all hospitals, no system to review transfers

System Assurance ACSCalifornia Analytic Monitoring ToolsAgency uses tools to monitor performance Score: 2-5, annual report, databases accessed only by owners Integration of Trauma PlanTrauma plan integrated with mass casualty plan Score: 4-5, plans for integration, drills Outreach and PreventionTrauma system demonstrates prevention & outreach activities Score: 2-3, prevention & outreach occurring, not well coordinated Continuous Trauma Care Improvement Each hospital must improve care as measured by outcomes Score 2; mechanism for review, not standardized, no state registry Rehabilitation AvailabilityAdequate rehabilitation facilities have been integrated into the system Score: 1; no written standards, no requirement for rehab services to contribute outcomes data

System Assurance ACSCalifornia Financial & QI linkageFinancial aspects integrated into quality improvement Score: 1; no cost data collected, no cost recovery data, no outside financial data Competent WorkforceLead authority assures a competent workforce Score: 1-4; lack of standards for nursing and physicians* Enforce Law, Rules Regulations Lead authority protects public welfare by enforcing laws, rules & regulations as they pertain to trauma Score: 2-5; accreditation processes encouraged, not acknowledged

Analysis Progress has been and is being made –Registry: Data dictionary will be approved 9/23 and data can be submitted as of 11/1 – gets to a state-wide registry –Authority and rules; within statute, language exists that allows for regulation to be developed for trauma systems

Challenges Development of Trauma System Rules –EMS authority –State wide Trauma Advisory Committee –Local EMS agencies Continuous Trauma Care Improvement –State wide Trauma Advisory Committee Funding –County-Federal Partnership Alameda and LA counties

ACS Perspective “San Diego was the Mesopotamia of trauma system development” California could and should be a leader in State-wide trauma systems. All the elements are in place for success. California has the physician leadership in trauma systems that no one else has. The challenge is here, we can & will meet it……