Ronald M. Stewart, MD Austin Trauma and Critical Care Conference June 3, 2016 No Disclosures Thank You to: . Robert Winchell, MD . Peter Fischer, MD . Susan Steinemann, MD . Dave Ciesla, MD Current status Brief history of Trauma Centers and Systems Trauma center care as a business-History The problems with “proliferation” Does trauma center level & volume matter? Current COT approach Summary
“One may long, as I do, for a gentler flame, a respite, a pause for musing. But perhaps there is no other peace for the artist than what he finds in the heat of combat…Instead, let us seek the respite where it is-in the very thick of battle. For in my opinion…, it is there.”
Albert Camus Robert K. Greenleaf; Larry C. Spears. Servant Leadership: A Journey into the Nature of Legitimate Power and Greatness 25th Anniversary Edition 415 ACS Verified Trauma Centers . Roughly and equal number of other TC Intense controversy in many regions . Number and type of trauma center Relevant . Cost . Stability of system . Outcomes and volume?
1913 The American College of Surgeons 1916 Earnest Codman: “A Study of Hospital Efficiency” 1917 ACS: The Hospital Standardization Program becomes the Joint Commission in 1952 1965 SSA—Medicare/Medicaid conditions of participation
6 National Academy of Sciences: Accidental Death and Disability: The neglected disease of modern society: . EMS . Emergency medicine . Trauma Surgeons . Trauma centers and systems
Public Hospitals – de facto trauma centers
7 Structure
Processes
Outcomes
(Structure, process, outcome, access, safety, costs and patient experience)
8
Set relevant high standards
Build and insure the right infrastructure, leadership and processes aimed at improving quality and reducing mortality. • People • Facilities • Resources
Foster the collection and use of risk adjusted clinical data for performance improvement
Implement a Verification Process by practicing clinical experts Pioneered and Developed by COT
10 ACS COT model for trauma center verification Professional Model – the criteria, rules and standards developed with the explicit statement that the patient’s needs come before the surgeon, the hospital or the organization Multidisciplinary professionals meeting, discussing, defining and redefining criteria for a trauma system – standards developed by consensus Partnering with state health agencies/States Evidenced based self governance—Freedom w responsibility
11 Regional priorities driven by institutional priorities Economic tide Increased governmental funding for trauma centers and trauma patients ACS verifies whether a center meets the criteria – Lead agency (usually state) designates trauma center Access significantly improved over past three decades Sophistication of care and systems have improved Mortality and morbidity have improved Trauma center as a business model has become popular
Cumulative disbursements from 3588 (2004-2013) Source: DSHS Hospital Designation 1998 2010 Level I 8 16 Level II 5 8 Level III 11 45 Level IV 108 185 Total 132 254 92% increase in Texas trauma centers 1998-2010 35% reduction
6,720 lives
United States Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Office of Analysis, Epidemiology, and Health Promotion (OAEHP), Compressed Mortality File (CMF) compiled from CMF 1968-1988, Series 20, No. 2A 2000, CMF 1989-1998, Series 20, No. 2E 2003 and CMF 1999-2001, Series 20, No. 2G 2004 on CDC WONDER On-line Database. Association of Funding and Designation of Trauma Centers (r=0.95) 1000
100
10
1 Log (stateLog (M)) dollars funding
0.1 120 140 160 180 200 220 240 260 Total Number of Texas Trauma Centers There has been a market change Trauma center care is a valued, profit center for many hospital systems Risk management strategy for economic cycles (Structure, process, outcome, access, safety, costs and patient experience)
There has been a market change Trauma center care is a valued, profit center for many hospital systems Risk management strategy for economic cycles (Structure, process, outcome, access, safety, costs and patient experience)
Is there a problem?
Outcomes Education Expertise Innovation Leadership
Volume and Level of Trauma Center does matter for outcomes.
Likely also matters for education, leadership, expertise and innovation Needs Based Assessment of Trauma Centers and Trauma Systems
Principle: trauma center number based on need Few regions able to operationalize Without strong leadership and authorization lead agencies not able to make difficult decisions Goals increasing access to trauma center care Trauma center designation more popular Currently “Proliferation” of Trauma Centers Past Centers dropped designation based based on economics
The designation of trauma centers is the responsibility of the governmental lead agency The lead agency should be guided by the local needs of the region(s). The collective interests of these citizens and patients supersede the interests of the providers and their respective organizations. Trauma center designation should be guided by the regional trauma plan based upon the needs Professional obligation of the surgeons, physicians, nurses, emergency medical services (EMS) providers, and public health professionals to work together Trauma system needs should be assessed using measures of trauma system access, quality of patient care, population mortality rates, and trauma system efficiency.
Called for a consensus group meeting centered on this question
Attendees . Surgeons . Health Care System Leadership . State Health System/TS Leadership . Trauma Center Executives . Public health experts . EMS Discussed the issues laid out in the policy statement – reached consensus around guidelines and metrics
1. Designation should be based upon need
2. Best interests of the population above the interests of stakeholder groups
3. Duty to work together, even in the face of competition
4. Level I trauma center is important to patient care & should be actively preserved by all in the system
5. Need for a practical tool to assist regions struggling with the issue of new trauma center designation
Population Median transport times Lead agency & stakeholder support for new ISS > 15 discharged from Level IV or undesignated centers Existing Level I Trauma Center ISS > 15 seen in Level I and II centers above 500/TC
Hawaii North Carolina Comments/Critique of the Tool
Population 4 Median transport times 0 Lead agency & stakeholder support 0 ISS > 15 D/C undesignated centers 0 Existing Level I Trauma Center NS ISS > 15 seen in Level I and II centers -1 Moderately helpful from provider vantage
Peter Fischer, The NC Experience
EMS transport times . A little difficult to interpret ▪ Need to include transfers somehow ISS> 15 at non-trauma centers . Good model performance using simply count of trauma patients (ICD9 800-959) Scoring system needs a zero Max is 4 Overall good performance in NC Model does not account for level of trauma center needed COT Tool doesn’t clearly define region Tool doesn’t actually measure need which is demand vs. capacity Too much weight to raw population & arbitrary Transport times simply represent colocation with population density—only way to impact in a rural region is to put the center rurally Community support = desire not need Severely injured patients discharged from non trauma center assumes ISS > 15 need trauma center; also likely redundant based on population points Existing trauma centers should also be assessed for capacity—not just presence Number ISS > 15 at TC is arbitrary limits volume which may be important to outcome Does not address over designation—only addresses need for new centers No guidance on where to place a center if tool predicts a new center is needed Needs to be a totally new EB tool Currently still a work in progress
Needs further refinement
May need to be a process rather than a simple instrument Preliminary report of NBATS Committee . Data accumulating using current tool . Second meeting to finalize plans Larger group to discuss strategic future direction of trauma system development in the US and globally . Partnership with National Highway Traffic Safety Administration and others– May 2017 Summary • Significant and dramatic improvements over the past nine decades in part due to Verification • Freedom with responsibility • Designation must be based on need • Volume does matter • Building consensus around – Doing the right thing for the patient – Doing things right for the patient
1. Designation should be based upon need
2. Best interests of the people above the interests of hospitals, physicians and nurses
3. Duty to work together, even in the face of competition
4. Level I trauma center is important to patient care & must be actively preserved by all in the system – Lead agency, EMS, Level II, III, IV centers
5. Tool to assist regions struggling with the issue of new trauma center designation still being developed
Your Leadership is Critical to Reducing Trauma Death and Disability (7 Ps) • Participatory and friendly • True to our Profession – What is the right thing for the patient? • Performance Improvement Process (ACS) • Problem solving • Passionate • Persistent • Patient Building consensus around the doing the right thing for the patient
How to Achieve Consensus in the Trauma System? • Patient centered – What is the right thing to do for the patients in our hospital…in our region? – Caution not to deceive ourselves • Patient
• Persistent
• Professional Frederick Douglass Advice to Daniel Hale Williams c. 1890
“You say you see what ought to be done. Well, hoping will do no good now or any time. There is only one way you can succeed and that is to override the obstacles in your way by the power that is within you. Do what you hope to do.”
Consensus Decision Making
• Higher level of decision making • Win-Win thinking • Don’t all have to agree, but agree enough that we can all live with and support the decision • Takes time • Dialogue • Respect and kindness