Minnesota Trauma System Development

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Minnesota Trauma System Development
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Overview

• The whats and whys of trauma system development
• History of trauma system development in Minnesota
• Phoenix of the Minnesota Trauma System
• Details of proposed system components
• Questions and answers

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Whats and Whys of Trauma Systems

• What is a trauma system?

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Whats and Whys of Trauma Systems

• What is a trauma system?

• A trauma system is an organized approach to
  facilitating multidisciplinary system response to
  severely injured patients.

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Whats and Whys of Trauma Systems

• A trauma system includes
• Injury prevention
• EMS interventions
• Emergency department interventions
• Intensive and surgical in-hospital care
• Rehabilitation
• Social services

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Whats and Whys of Trauma Systems

• Why do we need a trauma system?

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National Trauma Facts

• Traumatic injury is the leading cause of death
  for persons age 1 to 44 years old.
• In 1995 alone, injuries were responsible for
  147,891 deaths, 2.6 million hospital admissions,
  and more than 36 million emergency department
  visits nationwide.

Source Health Resources Services Administration
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National Trauma Facts

• Injury is Americas most expensive disease
  process, costing nearly 180 billion/year.
• Trauma causes more than 300,000 permanent
  disabilities annually.
• An estimated 25,000 trauma deaths annually are
  preventable.

Source Health Resources Services Administration
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National Trauma Facts

• Each year, nearly 25 of all Americans sustain an
  injury requiring medical attention.
• The death rate from unintentional injury is more
  than 50 higher in rural areas than in urban
  areas.

Source Health Resources Services Administration
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National Trauma Facts
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Minnesota Trauma Facts

• What is the incidence of trauma in Minnesota?

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Minnesota Trauma Facts

• Between 1995 and 1999, MN has averaged 610 motor
  vehicle crash deaths each year.
• Between 1995 and 1999, MN has averaged 31,000
  injury crashes each year.
• Estimated economic impact of 1.5 billion each
  year

Source Minnesota Department of Public Safety,
Office of Traffic Safety
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Minnesota Trauma Facts

• On an average day in 2000
• 283 crashes
• 1.7 deaths
• 122 people injured
• 4.591 million average daily cost

Source Minnesota Department of Public Safety,
Office of Traffic Safety
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Minnesota Trauma Facts

• The leading causes of injury-related death in MN
  are motor vehicle crashes, falls, and firearms
  (self-inflicted).
• The leading causes of injury-related
  hospitalization in MN are falls, motor vehicle
  crashes, falls, and poisonings (self-inflicted).
• The leading causes of injury-related emergency
  department treatment in MN are unintentional
  falls, contusions, and lacerations.

Source Minnesota Department of Health, Injury
and Violence Prevention Unit
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Minnesota Trauma Facts
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Minnesota Trauma Facts
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Minnesota Trauma Facts
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Minnesota Trauma Facts
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Whats and Whys of Trauma Systems

• Why do we need a trauma system in Minnesota?

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Why do we need a trauma system in Minnesota?

• Assuming a 15 reduction in all trauma deaths,
  9,222 lives saved from 1990 1999 (61,480
  injury-related deaths total).
• Assuming a 9 reduction in motor vehicle crash
  deaths, 515 lives saved from 1990 1999 (5,726
  motor vehicle-related deaths total).

Source Minnesota Department of Health, Injury
and Violence Prevention Unit
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Why do we need a trauma system in Minnesota?

• 43 other states have at least some elements of a
  trauma system
• Extensive data demonstrate
• average 15 reduction in trauma deaths
• 9 reduction in MV trauma deaths
• 15 reduction in hospital costs

Even Iowa has a statewide trauma system!
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Why do we need a trauma system in Minnesota?

• Coordinated and upgraded prehospital care (EMS)
• Improved treatment and transport guidelines
• Better coordinated health care
• Faster delivery of patient to definitive care
• Faster return of patient to local community for
  follow-up care or full rehabilitation

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Why do we need a trauma system in Minnesota?

• Costs savings
• Decreased hospital, disability and long term care
  costs (data show 15 reduction in hospital care
  costs)
• Decreased years of productive life lost
• Better outcomes through improved care and injury
  prevention
• Lives will be saved due to better education,
  faster delivery to appropriate care, and program
  review for quality improvement (data show
  decreased death rates up to 20)

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Why is a trauma system even more important in
rural Minnesota?

• In 2000, 70 of traffic crashes in Minnesota
  occurred in urban areas, but 71 of the states
  fatal crashes occurred in rural Minnesota.
• Increased time for ambulance response and before
  arrival to hospital in rural Minnesota add to the
  urgency.
• Source Minnesota Department of Public Safety,
  Office of Traffic Safety

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National Trauma Facts
Each day in the US, the equivalent number of
people die from trauma as if a fully loaded 757
crashed everyday.
Total 243 passengers  First Class 12
passengers Economy Class 231 passengers
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National Trauma Facts

• We would never tolerate this in airline
  performance why do we put up with it in our
  everyday lives?
• Why a trauma system in Minnesota?
• To decrease death and disability in Minnesota

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Whats and Whys of Trauma Systems

• What might a trauma system in Minnesota look like?

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BREAK

• (15 minutes)

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History of Trauma System Development in Minnesota
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History of Trauma System Development in Minnesota

• 1990-1991
• 101st Congress passed the Trauma Care Systems
  Planning and Development Act of 1990, providing
  grant funding for states to develop trauma
  systems.
• Minnesota Emergency Medical Services Advisory
  Council (MEMSAC) established Trauma Care Work
  Group.

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History of Trauma System Development in Minnesota

• 1992 - 1993
• Trauma Registry Alliance was awarded an EMS
  special project grant to demonstrate the
  feasibility of a statewide trauma registry.
• EMS section of the Minnesota Department of Health
  received federal grant to modify State EMS Plan
  to incorporate trauma.
• MEMSACs Trauma Care Work Group produced
  Minnesota Comprehensive Trauma System outlining a
  proposed trauma system.

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History of Trauma System Development in
Minnesota

• 1995 - MEMSACs Trauma Care Task Force produced
  the following
• Model Criteria for Trauma Stabilization
  Facilities and Community Trauma Facilities
• Trauma Stabilization Facility Model Protocols
  for Triage and Transfer of the Trauma Patient

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History of Trauma System Development in Minnesota

• 1996
• Emergency Medical Services Regulatory Board was
  created by the Legislature as a free-standing
  state agency, responsible for serving as the lead
  agency for EMS.
• Minnesota Statutes, 144E.01, subd. 6(b)(3)
• Duties of board... create, in conjunction with
  the department of public safety, a statewide
  injury and trauma prevention program

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Phoenix of the Minnesota Trauma System
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Phoenix of the Minnesota Trauma System

• April 2002, meeting convened by
• Minnesota Chapter of American College of Surgeons
• Minnesota Chapter of American College of
  Emergency Physicians
• June 2002, EMSC Supplemental Grant of 45,000
  awarded to the EMSRB for
• Trauma system development
• Conduct statewide trauma system/bioterrorism
  needs assessment

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Details of Proposed Systems Components

• Facility categorization and verification
• Triage and transport guidelines
• Statewide trauma registry

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Facility Verification
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Goals

• An inclusive system allowing participation from
  all hospitals
• Voluntary self selection of level of
  institutional trauma care (to be verified by
  state process or ACS)
• Reciprocity with border state hospitals

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Guiding principles for hospital self selection

• Four (possibly five) levels of trauma care will
  be established through a participatory
  rule-making process.
• Levels of care will likely resemble the American
  College of Surgeons, Committee on Trauma (ACS
  COT) criteria and the 1993 Minnesota
  recommendations.

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Guiding principles for hospital self selection

• Level of care selection
• Each hospital will decide on the level of trauma
  care they want/are able to provide.
• State resources (as they become available) will
  be used to support the development of levels III
  and IV centers.

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Guiding principles for hospital self selection

• Verification
• Levels I and II centers will likely be verified
  by the ACS COT system.
• Levels III and IV (possibly V) centers will be
  verified by a state system.
• To include a self reporting system
• Site visits may occur (resource dependent)
• The state will aspire to act as a consultant to
  hospitals to enhance trauma care.

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Guiding principles for hospital self selection

• Using the system
• Ambulance will take patient to hospital most
  appropriately equipped and staffed to handle the
  injury, as defined by regional guidelines.
• System will encourage transfer back to local
  hospital for recovering and rehabilitating
  patients after appropriate treatment at levels I
  or II facility.
• Funding for trauma team activation/ trauma care
  at all levels will be sought through legislation
  and payers.

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ACS COT Levels

• Level I trauma center
• Regional resource trauma center that has the
  capacity of providing leadership and total care
  for every aspect of injury from prevention
  through rehabilitation

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ACS COT Levels

• Level II trauma center
• Hospital that provides initial definitive trauma
  care regardless of the severity of injury, but
  may not be able to provide the same comprehensive
  care as a Level I trauma center and does not have
  trauma research as a primary objective

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ACS COT Levels

• Level III trauma center
• Hospital that provides assessment,
  resuscitation, emergency surgery, and
  stabilization while arranging for transfer to a
  Level I or Level II facility that can provide
  further definitive surgical care

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ACS COT Levels

• Level IV trauma center
• Medical facility that provides the stabilization
  and treatment of severely injured patients in
  remote areas where no alternative care is
  available

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ACS COT Levels

• Trauma receiving facility
• A clinic or small hospital located in sparsely
  populated area and often associated with a long
  term care facility
• - No surgical capabilities
• - Frequently staffed by PA or NP
• - Has basic lab and x-ray services
• - Initial assessment and resuscitation prior to
  transfer of injured patient

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Examples of ACS COT level of care criteria

• (for illustration purposes only)

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Level IV

• Trauma team (membership not specified)
• Trauma coordinator
• Key members of team having trauma education (ATLS
  or CALS)
• An operating room available
• Participation in the state trauma registry
• Transfer agreements in place

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Level III includes all Level IV components plus

• Trauma service and emergency department medical
  director
• Hospital departments of surgery, emergency,
  orthopedics, and anesthesia
• On call for the above departments and radiology
  and plastic surgery
• Presence of surgeon at resuscitation
• CT available
• Education, prevention, and performance
  improvement done by the hospital

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Some thoughts

• A system will decrease the variability in the
  care Minnesotans receive.
• Through a system performance improvement program,
  the quality of care will be raised.
• Our citizens and our communities will have better
  health through an organized approach.

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Triage and Transport Guidelines
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Criteria for considering

• Triage/transfer of trauma patients to a trauma
  center

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Adult Physiologic Criteria

• Level of consciousness and vital signs include
  but are not limited to
• Glasgow Coma Scale lt13
• Less than ALERT on AVPU lateralizing signs
• Loss of Consciousness gt5
• Respiratory Rate lt10 or gt29 need for intubation
• Heart rate gt120
• Systolic BP lt90

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Pediatric Physiology Criteria

• Level of consciousness and vital signs include
  but are not limited to
• 1. Abnormal responsiveness
• GCS lt13
• Less than ALERT on AVPU
• Abnormal or absent cry or speech
• Decreased response to parents or environmental
  stimuli
• Floppy or rigid muscle tone or not moving

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Pediatric Physiology Criteria

• 2. Loss of consciousness
• gt 5 minutes
• 3. Airway/breathing compromise
• Obstruction to airflow
• Gurgling, grunting, gasping
• Wheezing, stridor or noisy breathing
• Increased/excessive retractions or abdominal
  muscle use
• Nasal flaring, decreased/absent respiratory
  effort
• Respiratory rate outside normal range

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Pediatric Physiology Criteria

• 4. Circulatory compromise
• Cyanosis, mottling
• Paleness/pallor
• Obvious significant bleeding
• Absent or weak peripheral or central pulses
• Pulse rate or systolic BP outside normal range
• Capillary refill gt2 seconds with other abnormal
  findings

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Mechanism of Injury Risk Factors that Increase
the Risk of Unfavorable Outcome from Trauma

• 1. Death of occupant in same vehicle
• 2. Age lt 5 or gt 60 years

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Consider use of air transport from the scene of
the accident directly to a trauma center if

• 1. Ground transport time to local hospital is gt
  than air transport time to a trauma center.
• 2. Ground transport leaves the 911 Primary
  Service Area coverage compromised.

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Caveats
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1. Once the need for transport is recognized, do
not delay the process for lab or diagnostic
procedures that do not have an impact on the
transfer process or immediate resuscitation.
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2. The probability of positive outcome can be
improved by minimizing the time from injury to
appropriate definitive care.
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3. Health care providers in community hospitals
and regions of the state should develop specific
guidelines, based on local resources, that will
help to identify patients who may benefit from
early transfer to a trauma center.
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4. The purpose of triage/transport procedures
is to facilitate early transport of critical
trauma patients to the most appropriate health
care facility.
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Trauma Registry
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Questions and Answer Session