REGIONAL TRAUMA SYSTEMS: OPTIMAL ELEMENTS, INTEGRATION, AND ASSESSMENT SYSTEMS CONSULTATION GUIDE

COMMITTEE ON TRAUMA AMERICAN COLLEGE OF SURGEONS TRAUMA SYSTEM EVALUATION AND PLANNING COMMITTEE Regional Trauma Systems: Optimal Elements, Integration, and Assessment, American College of Surgeons Committee on Trauma: Systems Consultation Guide is intended as an instructive and evaluation tool to assist surgeons, health care institutions, and public health agencies in improving trauma systems and the care of injured patients. It is not intended to replace the professional judgment of the surgeon or health care administrator in individual circumstances. Th e American College of Surgeons and its Committee on Trauma cannot accept, and expressly disclaim, liability for claims arising from the use of this work.

Copyright © 2008 American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3211 All rights reserved.

ISBN 978-1-880696-33-0

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EDITOR IN CHIEF A. Brent Eastman, MD, FACS Avery B. Nathens, MD, PhD, FACS Chief Medical Offi cer Canada Research Chair in Trauma Systems N. Paul Whittier Chair of Trauma, SMH LJ Development Scripps-Health Division Head General Surgery and Director of Trauma San Diego, CA St Michael’s Hospital Martin R. Eichelberger, MD, FACS Toronto, ON Professor of Pediatrics and Surgery CONTRIBUTORS George Washington University School of Medicine Director, Trauma & Burn Service In Alphabetical Order Children’s National Medical Center Jane W. Ball, RN, DrPH Washington, DC Trauma Systems Consultant Th omas J. Esposito, MD, FACS ACS Trauma Systems Evaluation and Planning Chief, Section of Trauma Committee Department of Surgery Gaithersburg, MD Loyola University Medical Center Reginald A. Burton, MD, FACS Maywood, IL Trauma Director Alberto Esquenazi, MD Bryan LGH Medical Center Chair Department of Physical Medicine & Lincoln, NE Rehabilitation & Chief Medical Offi cer Sridhara Channarayapatn, MD Moss Rehab & Albert Einstein Medical Center Moss Rehab Hospital & Albert Einstein Medical Director Gait & Motion Analysis Laboratory and Center Regional Amputee Center Elkins Park, PA Philadelphia, PA David L. Ciraulo, DO, FACS, MPH Mary Sue Jones, RN, MS Associate Professor Department of Surgery Trauma System Coordinator Surgical Associates Delaware Health & Social Services, Division of Public Portland, ME Health, Offi ce of EMS Dover, DE Arthur Cooper, MD, FACS Professor of Surgery Christoph Robert Kaufmann, MD, FACS Director, Trauma and Pediatric Surgical Services Associate Medical Director, Trauma Service Columbia University Affi liation at Harlem Hospital Legacy Emanuel Hospital Center Portland, OR New York, NY Jon R. Krohmer, MD, FACEP Gail F. Cooper Deputy Chief Medical Offi cer Trauma Systems Consultant US Department of Homeland Security ACS Trauma Systems Evaluation and Planning Washington, DC Committee El Cajon, CA

Editor & Contributors iii Linda Laskowski-Jones, RN, MS, APRN, BC, Nels D. Sanddal, MS, REMT-B CCRN, CEN President Vice President, Emergency, Trauma & Aeromedical Critical Illness and Trauma Foundation Services Trauma Systems Consultant Christiana Care Health System ACS Trauma Systems Evaluation and Planning Newark, DE Committee Bozeman, MT Robert C. Mackersie, MD, FACS Professor of Surgery in Residence Heather A. Soucy San Francisco General Hospital Program Support Specialist San Francisco, CA Rural EMS & Trauma Technical Assistance Center Bozeman, MT N. Clay Mann, PhD, MS Associate Director for Research Shelly D. Timmons, MD, PhD, FACS Intermountain Injury Control Research Center Chief of Neurotrauma Division University of Utah School of Medicine Department of Neurosurgery Salt Lake City, UT University of Tennessee Health Science Center Memphis, TN J. Wayne Meredith, MD, FACS Medical Director, ACS Trauma Programs Jolene R. Whitney, MPA Richard T. Myers Professor and Chair, Department of Assistant Director General Surgery Bureau of Emergency Medical Services Division of Surgical Sciences Utah Department of Health Wake Forest University School of Medicine Salt Lake City, UT Winston-Salem, NC Michelle Wielgosz Holly Michaels Program Coordinator, Trauma Systems Consultation Program Coordinator, Trauma Systems Consultation American College of Surgeons American College of Surgeons Carol Williams Richard Mullins, MD, FACS Manager, Trauma Department Professor of Surgery American College of Surgeons Director, Trauma Service Robert J. Winchell, MD, FACS Oregon Health & Science University Head, Division of Trauma and Burn Surgery Portland, OR Maine Medical Center Avery B. Nathens, MD, PhD, FACS Portland, ME Canada Research Chair in Trauma Systems Development Division Head General Surgery & Director of Trauma St Michael’s Hospital Toronto, ON Michael F. Rotondo, MD, FACS Chair, ACS Trauma Systems Evaluation and Planning Committee Professor of Surgery and Vice Chairman for Clinical Aff airs Chief, Trauma & Surgical Critical Care East Carolina University School of Medicine Greenville, NC

iv Regional Trauma Systems: Optimal Elements, Integration, and Assessment

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Contributors ...... iii

Preamble ...... vii

Section 1: Trauma System Assessment Injury Epidemiology ...... 1 Indicators as a Tool for System Assessment ...... 2

Section 2: Trauma System Policy Development Statutory Authority and Administrative Rules ...... 5 System Leadership ...... 6 Coalition Building and Community Support ...... 7 Lead Agency and Human Resources Within the Lead Agency ...... 8 Trauma System Plan ...... 9 System Integration ...... 10 Financing ...... 11

Section 3: Trauma System Assurance Prevention and Outreach ...... 13 Emergency Medical Services ...... 14 Defi nitive Care Facilities ...... 17 System Coordination and Patient Flow ...... 20 Rehabilitation ...... 22 Disaster Preparedness...... 23 System-wide Evaluation and Quality Assurance ...... 24 Trauma Management Information Systems ...... 26 Research ...... 27

Table of Contents v Section 4: Postconsultation Measures Postconsultation Measures ...... 31 Assessment ...... 31 Policy Development ...... 32 Assurance ...... 34

Suggested Reading ...... 37

Appendix A: Glossary of Terms, Acronyms, and Abbreviations...... 43

Appendix B: Prereview Questionnaire (PRQ) ...... 49

vi Regional Trauma Systems: Optimal Elements, Integration, and Assessment

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Th e earliest organized systems of trauma care had 2 History of the American College components: (1) a concentration of care at centers of Surgeons Trauma System dedicated to the care of injured patients; and (2) Consultation Process prehospital bypass such that severely injured patients were transported not to the closest facility, but to Historically, in the United States, care of injured trauma centers. Th e focus on transport and defi nitive patients focused on trauma centers, not trauma care facilities, although relatively simple, was associated systems. Th is focus stemmed from the existence of with a signifi cant reduction in preventable deaths large county hospitals, which became de facto trauma and injury-related mortality within the region served. centers. Dedicated trauma centers, beyond these county Th ese systems typically served population-dense urban hospitals, were developed beginning in 1966. Th ere centers such that the designation of relatively few Level was also the sporadic development of trauma systems I or II centers was suffi cient to address local needs. beginning with the state of Illinois designating trauma With an increasing recognition of the burden of injury centers (a “system”) in 1971 and Maryland creating the associated with trauma outside of major metropolitan statewide Shock Trauma System in Baltimore. Other areas, including suburban and rural environments, regions followed, such as Orange County, California, it became evident that this exclusive approach to and San Diego, California, in the early 1980s. trauma center designation was inadequate. To better Th e fi rst document to establish resource and process serve the needs of the entire population, systems with standards for trauma centers was published in the an inclusive confi guration were implemented. Th ese Bulletin of the American College of Surgeons in 1976 systems, in which all acute care facilities participate to and titled “Optimal Hospital Resources for Care of the the extent that their resources allow, served 2 purposes: Seriously Injured.” Th is document formed the basis for (1) Th ey provided all centers with a means to assess and the American College of Surgeons (ACS)-Committee stabilize the conditions of patients before transport to on Trauma (COT) Trauma Center Verifi cation Level I or II centers if indicated. (2) Th ey allowed for Program. It was during trauma center verifi cation site less severely injured patients to be cared for within their visits that it became evident there was also great interest community. Recent evidence suggests that inclusive in having assistance in developing trauma systems. systems of trauma care are associated with a reduction However, at that time, the ACS-COT did not have the in injury-related mortality within a region compared necessary tools or processes to provide this service. with exclusive systems. In 1992, under the auspices of the Health Resources Organized systems of trauma care are more than and Services Administration (HRSA), the Model defi nitive care facilities and a means to transport Trauma Care System Plan was developed for the United patients. Th e system must be grounded in legislation, States. Th e HRSA Model Trauma plan was used as the with policies and procedures to ensure that the system basis for the development of the ACS-COT Trauma continues to meets regional needs. Th us, there must Systems Consultation Program in 1996, to meet be a means to ensure adequate funds and personnel this national need. Th e ACS-COT multidisciplinary to support systems operations, continuing quality committee established the following fundamental improvement, and injury surveillance to identify principles for the Trauma Systems Consultation emergent new threats. As the trauma system’s role Program: in reducing mortality and reintegrating the injured back into society was increasingly understood, the • Trauma systems should be inclusive. trauma system’s expanded role in post–acute care and • Th is program would be a consultation program as rehabilitation was recognized. opposed to a “verifi cation” program. It was thought that the program should be designed to assist any

Preamble vii region desirous of developing or improving an Guide was in order. Th e Institute of Medicine report already existing a trauma system. specifi cally acknowledged the ACS-COT Trauma System Evaluation and Planning Committee eff orts to • Th e process and consultation team would be promote regionalized, coordinated, and accountable multidisciplinary, refl ecting the multidisciplinary systems of care as a model for other emergency health nature of a trauma system. care responses. • Regions requesting a consultation visit would be able to customize the consultation process. Customization was accomplished by allowing the requesting lead Public Health Model agency to submit specifi c questions and issues the Th e events of September 11, 2001, led to a review region wanted to be addressed. Th e site visit team of the emergency medical services and the public could thereby include people with the requisite health infrastructure. What resulted was a broader expertise to serve the needs of the requesting agency understanding of the need for emergency care and and participants. public health systems to work in a more collaborative • All site visit work sessions would be inclusive and, and cooperative environment. Th ere came an awareness thereby, include all participants who represented of the need for prepared and fully interoperable the various components of the system (such as emergency medical, trauma care, and all-hazards surgeons, nurses, hospital administrators, emergency response systems and the recognition of the importance medical services agency, fi re chiefs, and paramedics of the public health infrastructure in responding to all and emergency medical technicians). Th erefore, all hazards, including terrorist activities. Add to this the discussions regarding the trauma system would take clear parallels between the epidemiologic behaviors place with input from all key participants. of illness and injuries and the existing public health strategies used for communicable disease eradication, Th e fi rst consultation visit was conducted in Montana and it becomes evident that an organized system of in 1999. During this initial consultation, the process trauma care should interface very well with public was tested and modifi ed, including the use of an health services. Th is interface is refl ected in HRSA’s electronic format for creating the consultation report. MTSPE, released in February 2006. Numerous consultation site visits have been conducted and enabled refi nements to the consultation process. Th e application of the public health model to trauma systems is based on the concept that injury as a disease A Client Manual was developed to assist states and can be prevented or its negative impacts decreased, or regions in preparing for the site visit. Th is document both, by primary, secondary, and/or tertiary prevention was followed by the development of a Reviewer Manual eff orts. Th ese actions are similar to actions taken to to assist review team participants to assess the level of reduce morbidity and mortality of infectious diseases. trauma system maturity and to recommend operational It is well recognized that excellent clinical trauma care processes to move the system forward. and eff ective injury prevention programs are necessary Th e need for a more scientifi cally based assessment to reduce death and disability due to injury. Th is tool grounded in the principles of public health was goal can be obtained through partnerships among identifi ed in 2002 by HRSA in cooperation with the trauma system managers, health care providers, and ACS-COT Trauma Systems Committee. Th e public public health agencies such that all 3 phases of injury health framework of assessment, policy development, prevention are addressed. Key objectives in reducing and assurance, the guiding principles and core the burden of injury and in making improvements in functions of public health, were also recognized as the the trauma care of persons with serious injury include basis for developing trauma systems including injury forging eff ective collaborations among trauma system control and prevention programs. Th is need led to the agencies, community health care facilities, and public development of the Model Trauma System Planning and health departments. Evaluation (MTSPE) document, released by HRSA in Th e public health system provides a conceptual 2006. framework for trauma system development, Based on this document and the recommendation management, and ongoing performance improvement. for regionalization by the 2006 Institute of Medicine Th e 3 core functions of public health services are report (Th e Future of Emergency Care in the US Health assessment, policy development, and assurance. Care System) and its experience in conducting trauma • Assessment is the regular and systematic collection system assessments, the ACS-COT concluded that and analysis of data from a variety of sources to a major update of the Trauma Systems Consultation viii Regional Trauma Systems: Optimal Elements, Integration, and Assessment determine the status and cause of a problem and to (1992) is illustrated in Table 1. Th e public health identify potential opportunities for interventions. community moved to make core function concepts more clear by describing 10 essential services that are • Policy development uses the results of the assessment key to providing public health at a local level. Th ese in an organized manner to establish comprehensive essential services of public health are as follows: policies intended to improve the public’s health. 1. Monitor health status to identify community • Assurance, agreed-on goals to improve the public’s health problems. health, is achieved by providing services directly, by requiring services through regulation, or by 2. Diagnose and investigate health problems and encouraging the actions of others (public or private). health hazards in the community. Th e core functions of the public health approach as 3. Inform, educate, and empower people about health they relate to trauma systems are demonstrated in issues. Figure 1. Th e relationship between these core functions 4. Mobilize community partnerships to identify and and trauma system components as described in HRSA’s solve health problems. Model Trauma Care System Components document

Figure 1. Core functions and essential services of the trauma system integrated with public health.

From Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006:18. *Note that research, one of the 10 essential services, is key and is placed in the center, as it is research that drives the system.

Preamble ix Table 1. Comparison of Public Health Core Functions and 1992 Model Trauma Care System Components*

Public Health Core Functions Trauma System Components

Core Function Essential Service 1992 Core Components Subcomponents Assessment Monitor health Evaluation Needs assessment Diagnose and investigate Data collection Research Policy Development Inform, educate, and Public information Injury prevention empower and education Trauma advisory committee Mobilize community partnerships Develop policies Legislation and Trauma system planning and regulations operations Regulations and rules Assurance Enforce laws Lead agency Ensure links to or provision Prehospital care Communications of care Triage and transport, medical direction, and treatment protocols Defi nitive care Facilities (designation), interfacility transfer, and rehabilitation Ensure competent workforce Human resources Workforce resources and educational preparation Evaluation Evaluation Data collection Research Interdisciplinary review Research committee

*From Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006:16.

5. Develop policies and plans that support individual Integration of the Trauma Systems and community health eff orts. Consultation Guide With the 6. Enforce laws and regulations that protect health HRSA’s MTSPE Document and ensure safety. Th e MTSPE document off ers a conceptual framework 7. Link people to needed personal health services, and for trauma system design and implementation. Th is ensure the provision of health care when otherwise trauma system consultation guide serves the purpose unavailable. of assisting in the trauma system consultation process, irrespective of its phase of development or scope. Th is 8. Ensure a competent public health and personal document thus serves to take the MTSPE conceptual health care workforce. framework and convert it into an assessment tool to 9. Evaluate eff ectiveness, accessibility, and quality of be used at the time of trauma system consultation. personal and population-based health services. Th e MTSPE contains a self-assessment tool for trauma system planning, development, and evaluation. Th is 10. Conduct research to attain new insights and tool, referred to as the BIS (benchmarks, indicators, innovative solutions to health problems. x Regional Trauma Systems: Optimal Elements, Integration, and Assessment and scoring), serves to allow individuals within the public health approach. To facilitate this translation, system to identify gaps in their system and monitor we have identifi ed the benchmarks and indicators their progress over time. Th e components of the BIS by their numbers (using the same numbers as in the are as follows: HRSA document), preceded by a B (benchmark) or an I (indicator), in parentheses following system elements. Benchmarks are global overarching goals, expectations, In their simplest form, the indicators represent the or outcomes. In the context of the trauma system, a optimal elements of a system and are described as such benchmark identifi es a broad system attribute. in their sections. Indicators are tasks or outputs that characterize the We attempted to ensure that the needs of the general benchmark. Indicators identify actions or capacities population and special populations would be met. within the benchmark and are the measurable Special populations include children; people who are components of a benchmark. elderly, disabled, and dispossessed (poor, homeless, and Scoring breaks down the indicator into completion institutionalized); and tribal nations. We additionally steps. Scoring provides an assessment of the current tried to achieve a workable balance in the needs of status and marks progress over time toward reaching a patients, providers, payers, and the public. certain milestone. Th is document is consistent with and supports the In development of the Regional Trauma Systems: concepts contained in the following: Optimal Elements, Integration, and Assessment • Emergency Medical Services for Children Program document, we strived to maintain consistency with the performance measures for state partnership grants BIS and sought to identify benchmarks and indicators appropriate to the various trauma system components. • Centers for Disease Control and Prevention Field Our broad objectives were to provide context and Triage Guidelines substance to the conceptual framework proposed in • National Highway Traffi c Safety Administration’s Th e the MTSPE. Th is approach provides for a practical Trauma System Agenda for the Future application of the MTSPE at the time of trauma system consultation and allows stakeholders to readily Th e introductions to the 4 sections of this doument are translate assessments and recommendations provided from the MTSPE. at the time of consultation into the context of the

Preamble xi

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ASSESSMENT ethnic groups) to ensure that specifi c needs or risk Regular systematic collection, assembly, analysis, and factors are identifi ed. It is critical to assess rates dissemination of information on the health of the of injury appropriately and, thus, to identify the community appropriate denominator (for example, admissions per 100,000 population). Without such a measure, it becomes diffi cult to provide valid comparisons across geographic regions and over time. Injury Epidemiology To establish injury policy and develop an injury Purpose and Rationale prevention and control plan, the trauma system, in conjunction with the state or regional epidemiologist, Injury epidemiology is concerned with the evaluation should complete a risk assessment and gap analysis of the frequency, rates, and pattern of injury events in using all available data. Th ese data allow for an a population. Injury pattern refers to the occurrence assessment of the “injury health” of the population of injury-related events by time, place, and personal (community, state, or region) and will allow for the characteristics (for example, demographic factors such assessment of whether injury prevention programs are as age, race, and sex) and behavior and environmental available, accessible, eff ective, and effi cient. exposures, and, thus, it provides a relatively simple form of risk-factor assessment. An ongoing part of injury epidemiology is public health surveillance. In the case of injury surveillance, Th e descriptive epidemiology of injury among the the trauma system provides routine and systematic whole jurisdictional population (geographic area data collection and, along with its partners in public served) within a trauma system should be studied and health, uses the data to complete injury analysis, reported. Injury epidemiology provides the data for interpretation, and dissemination of the injury public health action and becomes an important link information. Public health offi cials and trauma leaders between injury prevention and control and trauma should use injury surveillance data to describe and system design and development. Within the trauma monitor injury events and emerging injury trends system, injury epidemiology has an integral role in in their jurisdictions; to identify emerging threats describing the root causes of injury and identifying that will call for a reassessment of priorities and/or patterns of injury so that public health policy and reallocation of resources; and to assist in the planning, programs can be implemented. Knowledge of a region’s implementation, and evaluation of public health injury epidemiology enables the identifi cation of interventions and programs. priorities for directing better allocation of resources, the nature and distribution of injury prevention activities, Optimal Elements* fi nancing of the system, and health policy initiatives. I. Th ere is a thorough description of the Th e epidemiology of injury is obtained by analyzing epidemiology of injury in the system jurisdiction data from multiple sources. Th ese sources might using population-based data and clinical databases. include vital statistics, hospital administrative discharge (B-101) databases, and data from emergency medical services a. Th ere is a through description of the (EMS), emergency departments (EDs), and trauma epidemiology of injury mortality in the system registries. Motor-vehicle crash data might also prove useful, as would data from the criminal justice system focusing on interpersonal confl ict. It is important to assess the burden of injury across specifi c population * Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health groups (for example, children, elderly people, and Resources and Services Administration; 2006.

Trauma System Assessment 1 jurisdiction using population-based data. health surveillance. Th ere is concurrent (I-101.1) access to the databases (ED, trauma, prehospital, medical examiner, and public b. Th ere is a description of injuries within health epidemiology) for the purpose of the trauma system jurisdiction, including routine surveillance and monitoring of health the distribution by geographic area, high- status that occurs regularly and is a shared risk populations (pediatric, elderly, distinct responsibility. (I-304.2) cultural/ethnic, rural, and others), incidence, prevalence, mechanism, manner, intent, Prereview Questionnaire mortality, contributing factors, determinants, 1. Describe the epidemiology of injury in your region morbidity, injury severity (including death), and unique features of: and patient distribution using any or all the following: vital statistics, ED data, EMS data, a. Children hospital discharge data, state police data (data b. Adolescents from law enforcement agencies), medical examiner data, trauma registry, and other data c. Elderly people sources. Th e description is updated at regular d. Other special populations intervals. (I-101.2) 2. Describe the databases that are used to formulate c. Th ere is comparison of injury mortality using the injury epidemiology profi le (for example, local, regional, statewide, and national data. population-based and clinical). (I-101.3) 3. Have system epidemiology profi le results d. Collaboration exists among EMS, public health (for example, mortality rates, distribution offi cials, and trauma system leaders to complete of mechanism, or intent) been compared injury risk assessments. (I-101.4) with benchmark values? If so, please provide e. Th e trauma system works with EMS and comparisons and origins of the benchmarks. public health agencies to identify special at-risk 4. Describe how emerging injury control patterns populations. (I-101.7) (for example, from trend or surveillance data) were II. Collected data are used to evaluate system identifi ed and acted on. performance and to develop public policy. (B-205) 5. Describe how ongoing and routine injury a. Injury prevention programs use trauma surveillance is completed and how results are management information system data to shared with constituent groups. develop intervention strategies. (I-205.4) Documentation Required III. Th e trauma, public health, and emergency Before the site visit: preparedness systems are closely linked. (B-208) ✔ No additional documentation required a. Th e trauma system and the public health system have established linkages, including On-site: programs with an emphasis on population- ✔ A copy of the most recent State and Territorial based public health surveillance and evaluation Injury Prevention Directors Association assessment for acute and chronic traumatic injury and report injury prevention. (I-208.1) ✔ Copy of the injury epidemiology report or profi le IV. Th e jurisdictional lead agency, in cooperation with the other agencies and organizations, uses analytic tools to monitor the performance of population- based prevention and trauma care services. (B-304) Indicators as a Tool a. Th e lead agency, along with partner for System Assessment organizations, prepares annual reports on the Purpose and Rationale status on injury prevention and trauma care in the state, regional, or local areas. (I-304.1) In the absence of validated national benchmarks, or norms, the benchmarks, indicators and scoring (BIS) b. Th e trauma system management information process included in the Health Resources and Services system database is available for routine public Administration’s Model Trauma System Planning and

2 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Evaluation document provides a tool for each trauma Optimal Element* system to defi ne its system-specifi c health status I. Assurance to constituents that services necessary benchmarks and performance indicators and to use to achieve agreed-on goals are provided by a variety of community health and public health encouraging actions of others (public or private), interventions to improve the community’s health status. requiring action through regulation, or providing Th e tool also addresses reducing the burden of injury as services directly. (B-300) a community-wide public health problem, not strictly as a trauma patient care issue. Prereview Questionnaire Th is BIS tool provides the instrument and process for a 1. Has a multidisciplinary stakeholder group relatively objective state and substate (regional) trauma participated in the scoring and consensus process system self-assessment. Th e BIS process allows for the associated with the BIS tool? If not, are there plans use of state, regional, and local data and assets to drive to do so? consensus responses to the BIS. It is essential that 2. If the process has been completed, how were the the BIS process be completed by a multidisciplinary fi ndings used? stakeholder group, most often the equivalent of a state trauma advisory committee. Th e BIS process can help 3. Is there a date (year/month) set for a reassessment focus the discussion on various system strengths and using the BIS tool to mark progress toward agreed- weaknesses, can be used to set goals or benchmarks, on goals or benchmarks? and provides the opportunity to target often limited Documentation Required resources and energies to the areas identifi ed as most critical during the consensus process. Th e BIS process Before the site visit: is useful to develop a snapshot of any given system ✔ No additional documentation required at a moment in time. However, its true usefulness is in repeated assessments that reveal progress toward On-site: achieving various benchmarks identifi ed in the previous ✔ Copies of recommendations or actions emanating application of the BIS. Th is process further permits from the BIS process the trauma system to refi ne goals to be attained before ✔ future reassessments using the tool. Notes or minutes from any multidisciplinary stakeholder group that applied the BIS

* Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

Trauma System Assessment 3

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POLICY DEVELOPMENT to policy development should include the building of Promoting the use of scientifi c knowledge in decision system infrastructure that can ensure system oversight making, which includes: and future development, enforcement, and routine monitoring of system performance; the updating of • building constituencies, laws, regulations or rules, and policies and procedures; • identifying needs and setting priorities, and the establishment of best practices across all phases of intervention. Th e success of the system in • using legislative authority and funding to develop plans reducing morbidity and mortality due to traumatic and policies to address needs, and injury improves when all service providers and system • ensuring the public’s health and safety. participants consistently comply with the rules, have the ability to evaluate performance in a confi dential manner, and work together to improve and enhance the trauma system through defi ned policies. Statutory Authority and Administrative Rules Optimal Elements* I. Comprehensive state statutory authority and Purpose and Rationale administrative rules support trauma system leaders Reducing morbidity and mortality due to injury is and maintain trauma system infrastructure, the measure of success of a trauma system. A key planning, oversight, and future development. element to this success is having the legal authority (B-201) necessary to improve and enhance care of injured a. Th e legislative authority states that all the people through comprehensive legislation and through trauma system components, emergency medical implementing regulations and administrative code, services (EMS), injury control, incident including the ability to regularly update laws, policies, management, and planning documents work procedures, and protocols. In the context of the trauma together for the eff ective implementation of system, comprehensive legislation means the statutes, the trauma system (infrastructure is in place). regulations, or administrative codes necessary to meet (I-201.2) or exceed a predescribed set of standards of care. It also refers to the operating procedures necessary to b. Administrative rules and regulations direct continually improve the care of injured patients from the development of operational policies and injury prevention and control programs through procedures at the state, regional, and local postinjury rehabilitation. Th e ability to enforce laws levels. (I-201.3) and rules guides the care and treatment of injured II. Th e lead agency acts to protect the public welfare patients throughout the continuum of care. by enforcing various laws, rules, and regulations as Th ere must be suffi cient legal authority to establish a they pertain to the trauma system. (B-311) lead trauma agency and to plan, develop, maintain, a. Laws, rules, and regulations are routinely and evaluate the trauma system during all phases of reviewed and revised to continually strengthen care. In addition, it is essential that as the development and improve the trauma system. (I-311.4) of the trauma system progresses, included in the legislative mandate are provisions for collaboration, coordination, and integration with other entities also engaged in providing care, treatment, or surveillance * Th is section adapted from Health Resources and Services Administration. activities related to injured people. A broad approach Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

Trauma System Policy Development 5 Prereview Questionnaire trauma system evaluation and research to ensure that 1. Describe how the current statutes and regulations the right patient, right hospital, and right time goals allow the state or region to: are met. Th ere is a strong role for the trauma system leadership in conveying trauma system messages, a. develop, plan, and implement the trauma building communication pathways, building coalitions, system, and collaborating with relevant individuals and groups. b. monitor and enforce rules, Th e marketing communication component of trauma system development and maintenance begins with c. designate the lead agency, a consensus-built public information and education d. collect and protect confi dential data, and plan. Th e plan should emphasize the need for close collaboration between coalitions and constituency e. protect confi dentiality of the quality groups and increased public awareness of trauma as improvement process. a disease. Th e plan should be part of the ongoing 2. Describe the process by which trauma system and regular assessment of the trauma system and be policies and procedures are developed or updated updated as frequently as necessary to meet the changing to manage the system including: environment of the trauma system. a. the adoption of standards of care, When there are challenges to providing the optimal care to trauma patients within the system, the b. designation or verifi cation of trauma centers, leadership needs to eff ect change to produce the desired c. direct patient fl ow on the basis of designation, results. Broad system improvements require the ability to identify challenges and the resources and authority d. data collection, and to make changes to improve system performance. e. system evaluation. However, system evaluation is a shared responsibility. Although the leadership will have a key role in the 3. Within the context of statutes and regulation, acquisition and analysis of system performance data, describe how injury prevention, EMS, public the multidisciplinary trauma oversight committee will health, the needs of special populations, and share the responsibility of interpreting those data from emergency management are integrated or a broad systems perspective to help determine the coordinated within the trauma system. effi ciency and eff ectiveness of the system in meeting Documentation Required its stated performance goals and benchmarks. All stakeholders have the responsibility of identifying Before site visit: opportunities for system improvement and bringing ✔ Trauma system statutes and regulations them to the attention of the multidisciplinary ✔ committee or the lead agency. Often, subtle changes EMS statutes and regulations in system performance are noticed by clinical care On-site: providers long before they become apparent through more formal evaluation processes. ✔ Trauma system policies, procedures, standards, or other regulatory guidelines Perhaps the biggest challenge facing the lead agency is to synergize the diversity, complexity, and uniqueness of individuals and organizations into a fi nely tuned system for prevention of injury and for the provision of System Leadership quality care for injured patients. To meet this challenge, leaders in all phases of trauma care must demonstrate a Purpose and Rationale strong desire to work together to improve care provided In addition to lead agency staff and consultants (for to injured victims. example, trauma system medical director), there are other signifi cant leadership roles essential to developing Optimal Elements* mature trauma systems. A broad constituency of trauma I. Trauma system leaders (lead agency, trauma leaders includes trauma center medical directors and center personnel, and other stakeholders) use a nurse coordinators, prehospital personnel, injury process to establish, maintain, and constantly prevention advocates, and others. Th is broad group of trauma leaders works with the lead agency to * Th is section adapted from Health Resources and Services Administration. inform and educate others about the trauma system, Model Trauma System Planning and Evaluation. Rockville, MD: Health implements trauma prevention programs, and assists in Resources and Services Administration; 2006.

6 Regional Trauma Systems: Optimal Elements, Integration, and Assessment evaluate and improve a comprehensive trauma 5. Describe the process by which lead agency staff system in cooperation with medical, professional, would identify changes in system performance. governmental, and other citizen organizations. 6. Describe how the multidisciplinary advisory (B-202) committee is involved in trauma system II. Collected data are used to evaluate system performance evaluation. performance and to develop public policy. (B-205) Documentation Required III. Trauma system leaders, including a trauma-specifi c Before site visit: statewide multidisciplinary, multiagency advisory committee, regularly review system performance ✔ A comprehensive organizational chart that reports. (B-206) identifi es the lead agency staff (including contract employees) assigned to the trauma program (full- IV. Th e lead agency informs and educates state, or part-time) regional, and local constituencies and policy makers to foster collaboration and cooperation for ✔ A copy of the most recent trauma system system enhancement and injury control. (B-207) aggregated performance improvement report generated by the lead agency Prereview Questionnaire ✔ Organizational chart that illustrates the system 1. How does the lead agency bring constituency oversight committee, its subcommittee, and its groups together to review and monitor the trauma relationship to the lead agency system throughout each phase of care? On-site: 2. Describe the composition, responsibilities, and activities of the multidisciplinary trauma ✔ Copies of curriculum vitae for the trauma system system advisory committee(s) and the working leadership: state EMS director, trauma system relationship(s) with the trauma lead agency and manager, state medical director, and state trauma the EMS lead agency, if they are diff erent. director a. Identify pediatric representatives on the ✔ A copy of minutes or meeting notes pertaining to multidisciplinary trauma system advisory the identifi cation, discussion, and resolution of a committee and any pediatric advisory groups trauma system (rather than a trauma center) issue that provide input into trauma system development. b. Describe the process of involving experts in, Coalition Building and and advocates for, special populations and how Community Support they help drive regional trauma system policy. Purpose and Rationale c. Describe how the multidisciplinary advisory committee is involved in trauma system Coalition building is a continuous process of performance evaluation (for example, review cultivating and maintaining relationships with of system performance reports). constituents (interested citizens) in a state or region who agree to collaborate on injury control and trauma 3. Provide examples of how the lead agency system development. Key constituents include health and trauma system leadership (for example, professionals, trauma center administrators, prehospital trauma centers, trauma medical director, nurse care providers, health insurers and payers, data experts, coordinator, trauma administrator, and other consumers and advocates, policy makers, and media stakeholders) inform and educate policy makers, representatives. Th e coalition of key constituents elected offi cials, community groups, and others comprises the trauma system’s stakeholders. Th e about the trauma system, its strengths, and its involvement of these key constituents is important for improvement opportunities. the following: 4. Describe the process to build or expand eff ective • Trauma system plan development trauma leadership within the trauma system (for example, succession planning, leadership courses, • Regionalization: promoting collaboration rather than and workshops), including the lead agency and competition between trauma centers trauma centers. • System integration

Trauma System Policy Development 7 • State policy development: authorizing legislation and a. How has the community been approached to regulations identify injury control concerns? • Financing initiatives b. What key problems has the community identifi ed? • Disaster preparedness c. How do stakeholders bring system challenges Th e coalition should be eff ectively organized through or defi ciencies to the attention of the lead the formation of multidisciplinary state and regional agency? advisory groups to coordinate trauma system planning and implementation eff orts. Constituents also Documentation Required communicate with elected offi cials and policy leaders Before site visit: regarding the development and sustainability of the trauma system. Information and education are needed ✔ A list of organizations represented for trauma by constituents to be eff ective partners in policy system planning or injury control (for example, development for trauma system planning. Regular multidisciplinary state advisory committee, communication about the status of the trauma system subcommittees, and other groups supporting helps these key partners to recognize needs and progress trauma system development) made with trauma system implementation. On-site: One of the most eff ective ways to educate elected ✔ A list of all coalition members, and identify offi cials and the public is through an organized public organizations representing special populations information and education eff ort that may involve (for example, children and people who are elderly, a media campaign about the burden of injury in the need rehabilitation, or are disabled) state and the need for trauma system development. Information and education are important to reduce the ✔ Two or three diff erent types of communication to incidence of injury in all age groups and to demonstrate constituencies or the trauma system coalition (for the value of an eff ective trauma system when a serious example, notice of planning meetings, newsletter, injury occurs. activity report, coalition updates, or media message) Optimal Element* I. Th e lead agency informs and educates state, regional, and local constituencies and policy makers to foster collaboration and cooperation for Lead Agency and Human Resources system enhancement and injury control. (B-207) Within the Lead Agency Prereview Questionnaire Purpose and Rationale 1. What is the status of the trauma system’s coalition Each trauma system (state, regional, local, as defi ned in (for example, What is the status of recruiting state statute) should have a lead agency with a strong members and building a coalition? Is the coalition program manager who is responsible for leading the strong and active? Does the coalition need new trauma system. Th e lead agency, usually a government energy? Who is not currently involved but should agency, should have the authority, responsibility, be a part of your coalition?)? and resources to lead the planning, development, operations, and evaluation of the trauma system a. What is the role of the coalition members throughout the continuum of care. Th e lead agency, (constituents and stakeholders) in promoting empowered through legislation, ensures system integrity trauma system development? and provides for program integration with other b. What is the method and frequency for health care and community-based entities, namely, communicating with coalition members? public health, EMS, disaster preparedness, emergency management, law enforcement, social services, and 2. Describe how the trauma system leadership other community-based organizations. mobilizes community partners to improve the trauma system through eff ective communication Th e lead agency works through a variety of groups and collaboration. to accomplish the goals of trauma system planning, implementation, and evaluation. Th e ability to bring * Th is section adapted from Health Resources and Services Administration. multidisciplinary, multiagency advisory groups together Model Trauma System Planning and Evaluation. Rockville, MD: Health to accomplish trauma system goals is essential in Resources and Services Administration; 2006.

8 Regional Trauma Systems: Optimal Elements, Integration, and Assessment developing and maintaining the trauma system and is Prereview Questionnaire part of providing leadership to evolving and mature 1. Describe the number, position titles, and systems. percentage of full-time equivalency of all personnel Th e lead agency’s trauma system program manager within the lead agency or contract personnel coordinates trauma system design, the adoption of who have roles or responsibilities to the trauma minimum standards (prehospital and in-hospital), program. and provides for overall system evaluation through 2. Identify other personnel resources that support performance indicator assessment and assurance. In the trauma program activities of the lead agency addition to a trauma program manager, the lead agency (for example, epidemiology support from other must be suffi ciently staff ed to actively participate units within the health department, public health in each phase of development and in maintaining interns) the system through a clearly defi ned structure for decision making (policies and procedures) and through 3. Describe the adequacy of personnel resources proactive surveillance and evaluation. Minimum available to the lead agency to sustain trauma staffi ng usually consists of a trauma system program program assessment, policy development, and manager, data entry and analysis personnel, and assurance activities. monitoring and compliance personnel. Additional staff a. Identify impediments or barriers that hinder resources include administrative support and a part- system development. time commitment from the public health epidemiology service to provide system evaluation and research Documentation Required support. Before site visit: Within the leadership and governance structure of ✔ A comprehensive organizational chart that the trauma system, there is a role for strong physician identifi es the position of the lead agency within leadership. Th is role is usually fulfi lled by a full- or the broader governmental authority (for example, part-time trauma medical director within the lead health department) agency. ✔ A job description for the trauma program manager Optimal Elements* and the trauma medical director I. Comprehensive state statutory authority and On-site: administrative rules support trauma system leaders ✔ and maintain trauma system infrastructure, No additional documentation required planning, oversight, and future development. (B-201) a. Th e legislative authority (statutes and Trauma System Plan regulations) plans, develops, implements, manages, and evaluates the trauma system Purpose and Rationale and its component parts, including the Each trauma system, as defi ned in statute, should identifi cation of the lead agency and the have a clearly articulated trauma system planning designation of trauma facilities. (I-201.1) process resulting in a written trauma system plan. Th e plan should be built on a completed inventory of b. Th e lead agency has adopted clearly defi ned trauma system resources identifying gaps in services trauma system standards (for example, facility or resources and the location of assets. It should also standards, triage and transfer guidelines, include an assessment of population demographics, and data collection standards) and has topography, or other access enhancements (location suffi cient legal authority to ensure and enforce of hospital and prehospital resources) or barriers to compliance. (I-201.4) access. It is important that the plan identify special II. Suffi cient resources, including fi nancial and populations (for example, pediatric, elderly, in need of infrastructure-related, support system planning, burn care, ethnic groups, rural) within the geographic implementation, and maintenance. (B-204) area served and address the needs of those populations within the planning process. A needs assessment (or other method of identifying injury patterns, patient * Th is section adapted from Health Resources and Services Administration. care review/preventable death study) should also be Model Trauma System Planning and Evaluation. Rockville, MD: Health completed for initial trauma system planning and Resources and Services Administration; 2006.

Trauma System Policy Development 9 updated periodically as needed to assess system changes example, the plan includes references to over time. regulatory standards and documents and includes methods of data collection and Th e trauma system plan is developed by the lead trauma analysis. (I-203.4) agency based on the results of a needs assessment and other data resources available for review. It describes Prereview Questionnaire the system design, integrated and inclusive, with 1. Describe the process for the development or adopted standards of care for prehospital and hospital revision of the trauma system plan. personnel and a process to regularly review the plan over time. Th e plan is built on input from trauma a. Include the role of advisory and stakeholder advisory committees (or stakeholder groups) that assist groups in the process. in analyzing data, identifying resources, and developing 2. Is there ongoing assessment of trauma resources system standards of care, including system policies and asset allocation within the system? and procedures and overall system design. Ideally, although every stakeholder group may not be satisfi ed 3. Describe the process used to determine trauma with the plan or system design, the plan, to the extent system standards and trauma system policies. possible, should be based on consensus of the advisory a. How are they reviewed and evaluated? committees and stakeholder groups. Th ese advisory groups should be able to review the plan before fi nal b. What standards and policies exist for special adoption and approve the plan before it is submitted to populations, including rural and frontier the lead agency with authority for plan approval. regions? Th e trauma system plan is used to guide system c. How are specialized needs addressed, including development, implementation, and management. burns, spinal cord injury, traumatic brain Each component of the trauma system (for example, injury, and reimplantation? prehospital, hospital, communications, and transportation) is clearly defi ned and an established Documentation Required service level identifi ed (baseline) with goals for Before site visit: enhancement (benchmark). Within the plan are ✔ Copy of the written trauma system plan incorporated other planning documents used to ensure integration of similar services and build collaboration On-site: and cooperation with those services. Service plans for ✔ No additional documentation required emergency preparedness, EMS, injury prevention and control, public health, social services, and mental health are examples of services for which the trauma system plan should include an interface between agencies and System Integration services. Purpose and Rationale Optimal Element* Trauma system integration is essential for the daily care I. Th e state lead agency has a comprehensive of injured people and includes such services as mental written trauma system plan based on national health, social services, child protective services, and guidelines. Th e plan integrates the trauma public safety. Th e trauma system should use the public system with EMS, public health, emergency health approach to injury prevention to contribute to preparedness, and incident management. Th e reducing the entire burden of injury in a state or region. written trauma system plan is developed in Th is approach enables the trauma system to address collaboration with community partners and primary, secondary, and tertiary injury prevention stakeholders. (B-203) through closer integration with community health a. Th e trauma system plan clearly describes the programs and mobilizing community partnerships. system design (including the components Th e partnerships also include mental health, social necessary to have an integrated and inclusive services, child protection, and public safety services. trauma system) and is used to guide system Collaboration with the public health community also implementation and management. For provides access to health data that can be used for system assessment, development of public policy, and * Th is section adapted from Health Resources and Services Administration. informing and educating the community. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

10 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Integration with EMS is essential because this b. mental health, system is linked with the emergency response and c. social services, communication infrastructure and transports severely injured patients to trauma centers. Triage protocols d. law enforcement, should exist for treatment and patient delivery e. child protective services, and decisions. Regulations and procedures should exist for online and off -line medical direction. In the event of a f. public safety (such as fi re, lifeguard, mountain disaster aff ecting local trauma centers, EMS would have rescue, and ski patrol)? a major role in evacuating patients from trauma centers to safety or to other facilities or to make beds available Documentation Required for patients in greater need. Before site visit: Th e trauma system is a signifi cant state and regional ✔ No additional documentation required resource for the response to mass casualty incidents On-site: (MCIs). Th e trauma system and its trauma centers are essential for the rapid mobilization of resources ✔ No additional documentation required during MCIs. Preplanning and integration of the trauma system with related systems (public health, EMS, and emergency preparedness) are critical for rapid mobilization when a disaster or MCI occurs. Financing Th e extensive impact of disasters and MCIs on the Purpose and Rationale functioning of trauma centers and the EMS and public health systems within the aff ected region or state must Trauma systems need suffi cient funding to plan, be considered, and joint planning for optimal use of all implement, and evaluate a statewide or regional system resources must occur to enable a coordinated response of care. All components of the trauma system need to an MCI. Trauma system leaders need to be actively funding, including prehospital, acute care facilities, involved in emergency management planning to rehabilitation, and prevention programs. Lead agency ensure that trauma centers are integrated into the local, trauma system management requires adequate funding regional, and state disaster response plans. for daily operations and other important activities such as advisory committee meetings, development of Optimal Elements* regulations, data collection, performance improvement, I. Th e state lead agency has a comprehensive written and public awareness and education. Adequate funding trauma system plan based on national guidelines. to support the operation of trauma centers and their Th e plan integrates the trauma system with EMS, state of readiness to care for seriously injured patients public health, emergency preparedness, and within the state or region is essential. Th e fi nancial incident management. Th e written trauma system health of the trauma system is essential for ensuring its plan is developed in collaboration with community integrity and its improvement over time. partners and stakeholders. (B-203) Th e trauma system lead agency needs a process for a. Th e trauma system plan has established clearly assessing its own fi nancial health, as well as that of defi ned methods of integrating the trauma the trauma system. A trauma system budget should system plan with the EMS, emergency, and be prepared, and costs should be reported by each public health preparedness plans. (I-203.7) component, if possible. Routine collection of fi nancial data from all participating health care facilities is II. Th e trauma, public health, and emergency encouraged to fully identify the costs and revenues of preparedness systems are closely linked. (B-208) the trauma system, including costs and revenues pertaining to patient care, administrative, and trauma Prereview Questionnaire center operations. When possible, the lead agency 1. What is the trauma system’s collaboration fi nancial planning should integrate with the budgets and integration with EMS, public health, and and costs of the EMS system and disaster, rehabilitation, emergency management and programs such as: and prevention programs to enable development of a a. prevention programs, comprehensive fi nancial health report. Trauma system fi nancial planning should be related * Th is section adapted from Health Resources and Services Administration. to the trauma plan outcome measures (for example, Model Trauma System Planning and Evaluation. Rockville, MD: Health patient outcome measures such as mortality rates, Resources and Services Administration; 2006.

Trauma System Policy Development 11 length of stay, and quality-of-life indicators). Such a. How does the advisory committee participate information may demonstrate the value added by in the fi nancial review process? having a trauma system in place. b. How frequently are trauma system fi nancial Optimal Elements* reports published? I. Suffi cient resources, including fi nancial and c. Which fi nancial data are reported (lead agency infrastructure-related, support system planning, data, health facility data, or both)? implementation, and maintenance. (B-204) 2. What is the lead agency’s budget for the trauma a. Financial resources exist that support the system? planning, implementation, and ongoing management of the administrative and clinical 3. What is the source of funding available to support care components of the trauma system. (I-204.2) the development, operations, and management of the trauma system (for example, general funds, b. Designated funding for trauma system dedicated funds)? infrastructure support (lead agency) is legislatively appropriated. (I-204.3) 4. What fi nancial incentives and disincentives exist for trauma center participation in the trauma c. Operational budgets (system administration system? and operations, facilities administration and operations, and EMS administration and a. Specifi cally include arrangements for operations) are aligned with the trauma system uncompensated and undercompensated care. plan and priorities. (I-204.4) Documentation Required II. Th e fi nancial aspects of the trauma systems Before site visit: are integrated into the overall performance ✔ A copy of the lead agency’s budgets, identifying improvement system to ensure ongoing fi ne- line items directly related to goals and objectives of tuning and cost-eff ectiveness. (B-309) the trauma plan a. Collection and reimbursement data are ✔ A recent trauma system fi nancial report submitted by each agency or institution on at least an annual basis. Common defi nitions exist On-site: for collection and reimbursement data and are ✔ Letters and/or legislation that document fi nancial submitted by each agency. (I-309.2) or in-kind commitment Prereview Questionnaire ✔ Notice of awards and abstracts (active grants) 1. How does the lead agency track and analyze internal trauma system fi nances?

* Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

12 Regional Trauma Systems: Optimal Elements, Integration, and Assessment SECTION 3 T S A

ASSURANCE Activities that are essential to the development and Ensuring constituents that services necessary to achieve implementation of injury control and prevention agreed-on goals are provided by: programs include the following: • encouraging the actions of others (public and private), • A needs assessment focusing on the public information needed for media relations, public • requiring action through regulation, or offi cials, general public, and third-party payers, thus • providing services directly. ensuring a better understanding of injury control and prevention • Needs assessment for the general medical community, including physicians, nurses, prehospital care Prevention and Outreach providers, and others concerning trauma system and Purpose and Rationale injury control information Trauma systems must develop prevention strategies • Preparation of annual reports on the status of injury that help control injury as part of an integrated, prevention and trauma care in the system coordinated, and inclusive trauma system. Th e • Trauma system databases that are available and usable lead agency and providers throughout the system for routine public health surveillance should be working with business organizations, community groups, and the public to enact prevention Optimal Elements* programs and prevention strategies that are based on I. Th e lead agency informs and educates state, epidemiologic data gleaned from the system. regional, and local constituencies and policy Eff orts at prevention must be targeted for the intended makers to foster collaboration and cooperation for audience, well defi ned, and structured, so that the system enhancement and injury control. (B-207) impact of prevention eff orts is system-wide. Th e a. Th e trauma system leaders (lead agency, implementation of injury control and prevention advisory committees, and others) inform and requires the same priority as other aspects of the trauma educate constituencies and policy makers system, including adequate staffi ng, partnering with through community development activities, the community, and taking advantage of outreach targeted media messaging, and active opportunities. Many systems focus information, collaborations aimed at injury prevention and education, and prevention eff orts directly to the trauma system development. (I-207.2) general public (for example, restraint use, driving while intoxicated). However, a portion of these eff orts II. Th e jurisdictional lead agency, in cooperation with should be directed toward emergency medical services other agencies and organizations, uses analytic (EMS) and trauma care personnel safety (for example, tools to monitor the performance of population- securing the scene, infection control). Collaboration based prevention and trauma care services. (B-304) with public service agencies, such as the department a. Th e lead agency, along with partner of health is essential to successful prevention program organizations, prepares annual reports on the implementation. Such partnerships can serve to status of injury prevention and trauma care in synergize and increase the effi ciency of individual state, regional, or local areas (I-304.1) eff orts. Alliances with multiple agencies within the system, hospitals, and professional associations, working toward the formation of an injury control * Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health network, are benefi cial. Resources and Services Administration; 2006.

Trauma System Assurance 13 III. Th e lead agency ensures that the trauma system ✔ A representative sample of brochures, pamphlets, demonstrates prevention and medical outreach fl iers, and curricula for educational programs on activities within its defi ned service area. (B-306) injury prevention a. Th e trauma system is active within its jurisdiction in the evaluation of community- based activities and injury prevention and Emergency Medical Services response programs. (I-306.2) Purpose and Rationale b. Th e eff ect or impact of outreach programs (medical and community training and support Th e trauma system includes, and/or interacts with, and prevention activities) is evaluated as part many diff erent agencies, institutions, and systems. Th e of a system performance improvement process. EMS system is one of the most important of these (I-306.3) relationships. EMS is often the critical link between the injury-producing event and defi nitive care at a Prereview Questionnaire trauma center. Even though at its inception the EMS 1. List organizations dedicated to injury prevention system was a very broad system concept, over time, within the region and the issues they address (for EMS has come to be recognized as the prehospital care example, MADD, SADD, SafeKids Worldwide, component of the larger emergency health care system. Injury Free Coalition for Kids, American Trauma It is a complex system that not only transports patients, Society, university-based injury control programs). but also includes public access, communications, personnel, triage, data collection, and quality 2. Describe how the trauma lead agency has funded improvement activities. and coordinated system-wide injury prevention or outreach activities. Th e EMS system medical director must have statutory authority to develop protocols, oversee practice, and a. Which injuries (including pediatric injuries) establish a means of ongoing quality assessment to have been identifi ed and prioritized for ensure the optimal provision of prehospital care. If intervention strategies? not the same individual, the EMS system medical b. Identify any dedicated lead agency or other director must work closely with the trauma system agency staff member (full- or part-time) medical director to ensure that protocols and goals are responsible for injury prevention outreach and mutually aligned. Th e EMS system medical director coordination for the trauma system. must also have ongoing interaction with EMS agency medical directors at local levels, as well as the state c. What is the source of funding? EMS for Children program, to ensure that there is 3. Explain the evaluation process for injury understanding of and compliance with trauma triage prevention projects that are conducted by the lead and destination protocols. agency, trauma facilities, or other community- Ideally, a system should have some means of ensuring based organizations. whether resources meet the needs of the population. a. Identify any gaps in injury prevention eff orts To achieve this end, a resource and needs assessment for population groups in the state. evaluating the availability and geographic distribution of EMS personnel and physical resources is important Documentation Required to ensure a rapid and appropriate response. Th is Before site visit: assessment includes a detailed description of the ✔ distribution of ground ambulance and aeromedical A list of the number and nature of injury locations across the region. Resource allocations prevention activities conducted throughout the must be assessed on a periodic basis as needs dictate trauma system in the past year (for example, a redistribution of resources. In communities with activities directed at which mechanism or type full-time paid EMS agencies, ambulances should be of injury or which patient population, such as positioned according to predictable geographic or children and elderly people) temporal demands to optimize response effi ciencies. On-site: Such positioning schemes require strong prehospital ✔ data collection systems that can track the location of A copy of the state injury control and prevention occurrences over time. Periodic assessment of dispatch plan and transport times will also provide insight into whether resources are consistent with needs.

14 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Each region should have objective criteria dictating agencies typically serve rural areas and are essential to the level of response (advanced life support [ALS], the provision of immediate care to trauma patients, basic life support [BLS]), the mode of transport, in addition to provision of effi cient transportation and the disposition of the patient based on the to the appropriate facility. In some smaller facilities, location of the incident and the severity of injury. A EMS personnel also become part of the emergency mechanism for case-based review of trauma patients resuscitation team, augmenting hospital personnel. Th e that involves prehospital and hospital providers allows trauma care system program should reach out to these bidirectional information sharing and continuing volunteer agencies to help them achieve their vital role education, ensuring that expectations are met at in the outcome of care of trauma patients. However, it both ends. Ongoing review of triage and treatment must be noted that there is a delicate balance between decisions allows for continuing quality improvement expecting quality performance in these agencies and of the triage and prehospital care protocols. A more placing unrealistic demands on their response capacity. detailed discussion of in-fi eld (primary) triage criteria is In many cases, it is better to ensure that there is an provided in the section titled: System Coordination and optimal BLS response available at all times rather Patient Flow (p 20). than a sporadic or less timely response involving ALS personnel. Support to volunteer EMS systems may be Human Resources in the form of quality improvement activities, training, Periodic workforce assessments of EMS should be clinical opportunities, and support to the system conducted to ensure adequate numbers and distribution medical director. of personnel. EMS, not unlike other health care professions, experiences shortages and maldistribution Owing to the multidisciplinary nature of trauma of personnel. Some means of addressing recruitment, system response to injury, conferences that include all retention, and engagement of qualifi ed personnel levels of providers (for example, prehospital personnel, should be a priority. It is critical that trauma system nurses, and physicians) need to occur regularly with leaders work to ensure that prehospital care providers each level of personnel respected for its role in the care at all levels attain and maintain competence in trauma and outcome of trauma patients. Communication with care. Maintenance of competence should be ensured by and respect for prehospital providers is particularly requiring standards for credentialing and certifi cation important, especially in rural areas where exposure to and specifying continuing educational requirements for major trauma patients might be relatively rare. all prehospital personnel involved in trauma care. Th e Integration of EMS Within the Trauma System core curricula for First Responder, Emergency Medical In addition to its critical role in the prehospital Technician (EMT)-Basic, EMT-Intermediate, EMT- treatment and transportation of injured patients, EMS Paramedic, and other levels of prehospital personnel must also be engaged in assessment and integration have an essential orientation to trauma care for all ages. functions that include the trauma system and also However, trauma care knowledge and skills need to be public health and other public safety agencies. EMS continuously updated, refi ned, and expanded through agencies should have a critical role in ensuring targeted trauma care training such as Prehospital that communication systems are available and Trauma Life Support®, Basic Trauma Life Support®, have suffi cient redundancy so that trauma system and age-specifi c courses. Mechanisms for the periodic stakeholders will be able to assess and act to limit assessment of competence, educational needs, and death and disability at the single patient level and education availability within the system should be at the population level in the case of mass casualty incorporated into the trauma system plan. incidents (MCIs). Enhanced 911 services and a central Systems of excellence also encourage EMS providers communication system for the EMS/trauma system to to go beyond meeting state standards for agency ensure fi eld-to-facility bidirectional communications, licensure and to seek national accreditation. National interfacility dialogue, and all-hazards response accreditation standards exist for ground-based and communications among all system participants are air medical agencies, as well as for EMS educational important for integrating a system’s response. Wireless programs. In some states, agency licensure requirements communications capabilities, including automatic crash are waived or substantially simplifi ed if the EMS agency notifi cation, hold great promise for quickly identifying maintains national accreditation. trauma-producing events, thereby reducing delays in discovery and decreasing prehospital response intervals. EMS is the only component of the emergency health care and trauma system that depends on a large cadre Further integration might be accomplished through the of volunteers. In some states, substantially more than use of EMS data to help defi ne high-risk geographic half of all EMS agencies are staff ed by volunteers. Th ese and demographic characteristics of injuries within a

Trauma System Assurance 15 response area. EMS should assist with the identifi cation treatment, and transport is closely coordinated of injury prevention program needs and in the delivery with the established performance improvement of prevention messages. EMS also serves a critical role processes of the trauma system. (I-302.5) in the development of all-hazards response plans and in f. Th ere is a universal access number for citizens the implementation of those plans during a crisis. Th is to access the EMS/trauma system, with integration should be provided by the state and regional dispatch of appropriate medical resources. trauma plan and overseen by the lead agency. EMS Th ere is a central communication system should participate through its leadership in all aspects for the EMS/trauma system to ensure fi eld- of trauma system design, evaluation, and operation, to-facility bidirectional communications, including policy development, public education, and interfacility dialogue, and all-hazards response strategic planning. communications among all system participants. Optimal Elements* (I-302.7) I. Th e trauma system is supported by an EMS system g. Th ere are suffi cient and well-coordinated that includes communications, medical oversight, transportation resources to ensure that EMS prehospital triage, and transportation; the trauma providers arrive at the scene promptly and system, EMS system, and public health agency are expeditiously transport the patient to the well integrated. (B-302) correct hospital by the correct transportation a. Th ere is well-defi ned trauma system medical mode. (I-302.8) oversight integrating the specialty needs of the II. Th e lead trauma authority ensures a competent trauma system with the medical oversight for workforce. (B-310) the overall EMS system. (I-302.1) a. In cooperation with the prehospital certifi cation b. Th ere is a clearly defi ned, cooperative, and and licensure authority, set guidelines for ongoing relationship between the trauma prehospital personnel for initial and ongoing specialty physician leaders (for example, trauma trauma training, including trauma-specifi c medical director within each trauma center) courses and courses that are readily available and the EMS system medical director. (I-302.2) throughout the state. (I-310.1) c. Th ere is clear-cut legal authority and b. In cooperation with the prehospital responsibility for the EMS system medical certifi cation and licensure authority, ensure that director, including the authority to adopt prehospital personnel who routinely provide protocols, to implement a performance care to trauma patients have a current trauma improvement system, to restrict the practice training certifi cate, for example, Prehospital of prehospital care providers, and to generally Trauma Life Support or Basic Trauma ensure medical appropriateness of the EMS Life Support and others, or that trauma system. (I-302.3) training needs are driven by the performance d. Th e trauma system medical director is actively improvement process. (I-310.2) involved with the development, implementation, c. Conduct at least 1 multidisciplinary trauma and ongoing evaluation of system dispatch conference annually that encourages system and protocols to ensure they are congruent with team approaches to trauma care. (I-310.9) the trauma system design. Th ese protocols include, but are not limited to, which resources III. Th e lead agency acts to protect the public welfare to dispatch, for example, ALS versus BLS, air- by enforcing various laws, rules, and regulations as ground coordination, early notifi cation of the they pertain to the trauma system. (B-311) trauma care facility, prearrival instructions, a. Incentives are provided to individual agencies and other procedures necessary to ensure that and institutions to seek state or nationally resources dispatched are consistent with the recognized accreditation in areas that will needs of injured patients. (I-302.4) contribute to overall improvement across the e. Th e retrospective medical oversight of the EMS trauma system, for example, Commission system for trauma triage, communications, on Accreditation of Ambulance Services for prehospital agencies, Council on Allied Health * Th is section adapted from Health Resources and Services Administration. Education Accreditation for training programs, Model Trauma System Planning and Evaluation. Rockville, MD: Health and American College of Surgeons (ACS) Resources and Services Administration; 2006. verifi cation for trauma facilities. (I-311.6)

16 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Prereview Questionnaire BLS), including pediatric protocols and geriatric 1. Provide information on the last assessment of protocols if available EMS, including assessor and date. a. Describe the EMS system, including the number and competencies (that is, ALS Defi nitive Care Facilities or BLS) of ground transporting agencies, nontransporting agencies, and air medical Purpose and Rationale resources. Inclusive trauma systems are the systems that include all acute health care facilities, to the extent that their b. How are these resources allocated throughout resources and capabilities allow and in which the the region to serve the population? patient’s needs are matched to hospital resources and c. Describe the availability of enhanced 911 and capabilities. Th us, as the core of a regional trauma wireless E-911 access in your region. system, acute care facilities operating within an inclusive trauma system provide defi nitive care to the d. Identify any specialty pediatric transporting entire spectrum of patients with traumatic injuries. agencies and aeromedical resources. Acute care facilities must be well integrated into e. Describe the availability of pediatric equipment the continuum of care, including prevention and on all ground transporting units. rehabilitation, and operate as part of a network of trauma-receiving hospitals within the public health 2. Describe the procedures for online and off -line framework. All acute care facilities should participate medical direction, including procedures for the in the essential activities of a trauma system, including pediatric population. performance improvement, data submission to state a. Describe how EMS and trauma medical or regional registries, representation on regional direction and oversight are coordinated and trauma advisory committees, and mutual operational integrated. agreements with other regional hospitals to address interfacility transfer, educational support, and outreach. 3. Describe the prehospital workforce competencies Th e roles of all defi nitive care facilities, including in trauma: specialty hospitals (for example, pediatric, burn, severe a. Initial training and certifi cation/licensure traumatic brain injury [TBI], spinal cord injury [SCI]) requirements within the system should be clearly outlined in the regional trauma plan and monitored by the lead agency. b. Continuing education and recertifi cation/ Facilities providing the highest level of trauma care are relicensure requirements expected to provide leadership in education, outreach, c. Pediatric trauma training requirements for patient care, and research and to participate in the recertifi cation design, development, evaluation, and operation of the regional trauma system. Documentation Required In an inclusive system, patients should be triaged to the Before site visit: appropriate facility based on their needs and facility ✔ Guidelines for patient care delivery decisions resources. Patients with the least severe injuries might (primary or in-fi eld triage and destination be cared for at appropriately designated facilities within designation guidelines) their community, whereas the most severe should be triaged to a Level I or II trauma center. In rural and ✔ Map identifying the location of aeromedical frontier systems, smaller facilities must be ready to resources in the region resuscitate and initiate treatment of the major injuries On-site: and have a system in place that will allow for the fastest, safest transfer to a higher level of care. ✔ Protocols dictating level of EMS response (ALS or BLS), mode of transport, and disposition of the Trauma receiving facilities providing defi nitive care patient to patients with other than minor injuries must be specifi cally designated by the state or regional lead ✔ Requirements for medical oversight of all levels agency and equipped and qualifi ed to do so at a level of EMS agencies, ALS and BLS, transporting and commensurate with injury severity. To assess and nontransporting ensure that injury type and severity are matched to the ✔ Prehospital care treatment protocols (ALS and qualifi cations of the facilities and personnel providing

Trauma System Assurance 17 defi nitive care, the lead agency should have a process lead trauma centers within the region should assist in place that reviews and verifi es the qualifi cations of a in meeting educational needs while fostering a particular facility according to a specifi c set of resource team approach to care through annual educational and quality standards. Th is criteria-based process for multidisciplinary trauma conferences. Th ese activities review and verifi cation should be consistent with will do much to foster a sense of teamwork and a national standards and be conducted on a periodic functionally inclusive system. cycle as determined by the lead agency. When centers do not meet set standards, there should be a process for Integration of Designated Trauma Facilities suspension, probation, revocation, or dedesignation. Within the Trauma System Designated trauma facilities must be well integrated Designation by the lead agency should be restricted into all other facets of an organized system of trauma to facilities meeting criteria or statewide resource and care, including public health systems and injury quality standards and based on patient care needs of the surveillance, prevention, EMS and prehospital care, regional trauma system. Th ere should be a well-defi ned disaster preparedness, rehabilitation, and system regulatory relationship between the lead agency and performance improvement. Th is integration should be designated trauma facilities in the form of a contract, provided by the state and/or regional trauma plan and guidelines, or memorandum of understanding. overseen by the lead agency. Th is legally binding document should defi ne the relationships, roles, and responsibilities between the Each designated acute care facility should participate, lead agency and the medical leadership from each through its trauma program leadership, in all aspects designated trauma facility. of trauma system design, evaluation, and operation. Th is participation should include policy and legislative Th e number of trauma centers by level of designation development, legislative and public education, and and location of acute care facilities must be periodically strategic planning. In addition, the trauma program assessed by the lead agency with respect to patient and subspecialty leaders should provide direction and care needs and timely access to defi nitive trauma care. oversight to the development, implementation, and Th ere should be a process in place for augmenting and monitoring of integrated protocols for patient care used restricting, if necessary, the number and/or level of throughout the system (for example, TBI guidelines acute care facilities based on these periodic assessments. used by prehospital providers and nondesignated Th e trauma system plan should address means for transferring centers), including region-specifi c improving acute care facility participation in the primary (fi eld) and secondary (early transfer) triage trauma system, particularly in systems in which there protocols. Th e highest level trauma facilities should has been diffi culty addressing needs. provide leadership of the regional trauma committees Human Resources through their trauma program medical leadership. Th ese medical leaders, through their activities on Th e ability to deliver high-quality trauma care is these committees, can assist the lead agency and help highly dependent on the availability of skilled ensure that defi ciencies in the quality of care within the human resources. Th erefore, it is critical to assess system, relative to national standards, are recognized the availability and educational needs of providers and corrected. Educational outreach by these higher on a periodic basis. Because availability, particularly levels centers should be used when appropriate to help of subspecialty resources, is often limited, some achieve this goal. means of addressing recruitment, retention, and engagement of qualifi ed personnel should be a Optimal Elements* priority. Periodic workforce assessments should be I. Acute care facilities are integrated into a resource- conducted. Maintenance of competence should be effi cient, inclusive network that meets required ensured by requiring standards for credentialing and standards and that provides optimal care for all certifi cation and specifying continuing educational injured patients. (B-303) requirements for physicians and nurses providing care to trauma patients. Mechanisms for the periodic a. Th e trauma system plan has clearly defi ned assessment of ancillary and subspecialty competence, the roles and responsibilities of all acute care educational needs, and availability within the system facilities treating trauma and of facilities that for all designated facilities should be incorporated into provide care to specialty populations (for the trauma system plan. Th e lead trauma centers in rural areas will need to consider teleconferencing and * Th is section adapted from Health Resources and Services Administration. telemedicine to assist smaller facilities in providing Model Trauma System Planning and Evaluation. Rockville, MD: Health education on regionally identifi ed needs. In addition, Resources and Services Administration; 2006.

18 Regional Trauma Systems: Optimal Elements, Integration, and Assessment example, burn, pediatric, SCI, and others). a. Describe the availability and roles of specialty (I-303.1) centers within the system (pediatric, burn, TBI, SCI). II. To maintain its state, regional, or local designation, each hospital will continually work to improve the 2. Describe the roles of the nondesignated acute care trauma care as measured by patient outcomes. facilities in the trauma system. (B-307) a. Address their representation on the regional a. Th e trauma system engages in regular evaluation trauma committee. of all licensed acute care facilities that provide b. Do they submit registry and/or fi nancial data? trauma care to trauma patients and of designated trauma hospitals. Such evaluation involves c. What is their degree of engagement in the independent external reviews. (I-307.1) system-wide performance improvement process? III. Th e lead trauma authority ensures a competent workforce. (B-310) 3. Describe the process for verifi cation and designation. Briefl y outline the extent of authority a. As part of the established standards, set granted to the lead agency to receive applications appropriate levels of trauma training for and to verify, designate, and dedesignate regional nursing personnel who routinely care for trauma trauma centers. patients in acute care facilities. (I-310.3) 4. Describe your standards for trauma center b. Ensure that appropriate, approved trauma verifi cation (including pediatric standards) and training courses are provided for nursing the extent to which they are aligned with national personnel on a regular basis. (I-310.4) standards. c. In cooperation with the nursing licensure a. Describe any waivers or program fl exibility authority, ensure that all nursing personnel granted for centers not meeting verifi cation who routinely provide care to trauma patients requirements. have a trauma training certifi cate (for example, Advanced Trauma Care for Nurses, Trauma b. Describe the process and frequency of use of Nursing Core Course, or any national or dedesignation of trauma centers. state trauma nurse verifi cation course). As 5. Outline how the geographic distribution and an alternative after initial trauma course number of designated acute care facilities is aligned completion, training can be driven by the with patient care needs. performance improvement process. (I-310.5) a. Describe the process by which additional d. In cooperation with the physician licensure trauma centers are brought into the system. authority, ensure that physicians who routinely provide care to trauma patients have a current b. Describe the system response to the voluntary trauma training certifi cate of completion, for withdrawal of designation by acute care example, Advanced Trauma Life Support® facilities. (ATLS®) and others. As an alternative, c. Describe the mechanism for tracking and physicians may maintain trauma competence monitoring patient volume and fl ow between through continuing medical education programs centers and how this infl uences the overall after initial ATLS completion. (I-310.8) confi guration of designated facilities. e. Conduct at least 1 multidisciplinary trauma 6. Describe your system for assessing the adequacy conference annually that encourages system and of the workforce resources available within team approaches to trauma care. (I-310.9) participating centers. f. As new protocols and treatment approaches a. Address nursing and subspecialty needs (trauma are instituted within the system, structured or general surgery, intensivists, neurosurgeons, mechanisms are in place to inform all personnel orthopedic surgeons, anesthetists, pediatric about the changes in a timely manner. (I-310-10) surgeons, and others, as required). Prereview Questionnaire b. What human resource defi ciencies have been 1. Describe the extent to which all acute care facilities identifi ed, and what corrective actions have participate in the trauma system. been taken?

Trauma System Assurance 19 7. Describe the educational standards and most critically injured trauma patient is often easy to credentialing for emergency physicians and identify at the scene by virtue of the presence of coma nursing staff , general surgeons, specialty surgeons, or hypotension. However, in some circumstances, and critical care nurses caring for trauma patients the patients requiring the resources of a Level I or II in designated facilities. center may not be immediately apparent to prehospital providers. Primary or fi eld triage criteria aid providers a. What regional educational multidisciplinary in identifying which patients have the greatest conferences are provided to care providers? likelihood of adverse outcomes and might benefi t from Who is responsible for organizing these events? the resources of a designated trauma center. Even if the Documentation Required need is identifi ed, regional geography or limited air Before site visit: medical (or land) transport services might not allow for direct transport to an appropriate facility. ✔ Copy of the document outlining the process for designation, redesignation, and dedesignation (if Primary triage of a patient from the fi eld to a center necessary) of trauma centers capable of providing defi nitive care is the goal of the trauma system. However, there are circumstances (for ✔ Copy of the standards (if other than ACS) used for example, airway management, rural environments, trauma center verifi cation inclement weather) when triaging a patient to a closer ✔ A list of acute care facilities with the following data facility for stabilization and transfer is the best option for each: for accessing defi nitive care. Patients sustaining severe injuries in rural environments might need immediate Level of designation/verifi cation assessment and stabilization before a long-distance A geographic map showing the location, transport to a trauma center. In addition, evaluation catchment areas, and designation for all acute of the patient might bring to light severe injuries care facilities for which needed care exceeds the resources of the initial receiving facility. Some patients might have Patient volume (total and with Injury Severity specifi c needs that can be addressed at relatively few Score [ISS] >15, if available) centers within a region (for example, pediatric trauma, ▪ Emergency department (ED) visits burns, severe TBI, SCI, and reimplantation). Finally, temporary resource limitations might necessitate the ▪ Admissions transfer of patients between acute care facilities. A list of trauma facilities with their level of Secondary triage at the initial receiving facility has designation and trauma patient volume (total several advantages in systems with a large rural or and with ISS >15) suburban component. Th e ability to assess patients On-site: at nondesignated or Level III to V centers provides an opportunity to limit the transfer of only the most ✔ A copy of the sample contract or memorandum severely injured patients to Level I or II facilities, thus of understanding between the lead agency and a preserving a limited resource for patients most in trauma center if such exists need. It also provides patients with lesser injuries the ✔ Flyer for the most recent multidisciplinary possibility of being cared for within their community. educational trauma conference Th e decision to transfer a trauma patient should be based on objective, prospectively agreed-on criteria. Established transfer criteria and transfer agreements will minimize discussions about individual patient System Coordination transfers, expedite the process, and ensure optimal and Patient Flow patient care. Delays in transfer might increase Purpose and Rationale mortality, complications, and length of stay. A system with an excess of transferred patients might tax the To achieve the best possible outcomes, the system must resources of the regional trauma facility. Conversely, be designed so that the right patient is transported to inappropriate retention of patients at centers without the right facility at the right time. Although on the adequate facilities or expertise might increase the risk surface this objective seems relatively straightforward, of adverse outcomes. Given the importance of timely, patients, geography, and transportation systems appropriate interfacility transfers, the time to transfer, often conspire to present signifi cant challenges. Th e as well as the rates of primary and secondary overtriage

20 Regional Trauma Systems: Optimal Elements, Integration, and Assessment and undertriage, should be evaluated on a regular II. Acute care facilities are integrated into a resource- basis, and corrective actions should be instituted when effi cient, inclusive network that meets required problems are identifi ed. Data derived from tracking and standards and that provides optimal care for all monitoring the timeliness of access to a level of trauma injured patients. (B-303) care commensurate with injury type and severity should a. When injured patients arrive at a medical be used to help defi ne optimal system confi guration. facility that cannot provide the appropriate A central communications center with real-time access level of defi nitive care, there is an organized to information on system resources greatly facilitates and regularly monitored system to ensure that the transfer process. Ideally, this center identifi es a the patients are expeditiously transferred to the receiving facility, facilitates dialogue between the appropriate system-defi ned trauma facility. transferring and receiving centers, and coordinates (I-303.4) interfacility transport. Prereview Questionnaire To ensure that the system operates at the greatest 1. Describe the source of prehospital trauma triage effi ciency, it is important that patients are repatriated protocols, and specify whether they are consistent back to community hospitals once the acute phase of with national guidelines. trauma care is complete. Th e process of repatriation opens up the limited resources available to care for a. Describe how children and patients with severe severely injured patients. In addition, it provides an TBI and SCI are triaged from the fi eld to opportunity to bring patients back into their local appropriate facilities. environment where their social network might help 2. Within the system, what criteria are used to guide reintegrate patients into their community. the decision to transfer patients to an appropriate Optimal Elements* resource facility and are these criteria uniform across all centers? I. Th e trauma system is supported by an EMS system that includes communications, medical oversight, 3. Specify whether there are interfacility transfer prehospital triage, and transportation; the trauma agreements to address the needs of each of the system, EMS system, and public health agency are following: well integrated. (B-302) a. Transfer to an appropriate resource facility a. Th ere are mandatory system-wide prehospital b. TBI triage criteria to ensure that trauma patients are transported to an appropriate facility based on c. SCI their injuries. Th ese triage criteria are regularly d. Reimplantation evaluated and updated to ensure acceptable and system-defi ned rates of sensitivity and e. Burns specifi city for appropriately identifying a major f. Children trauma patient. (I-302.6) g. Repatriation b. Th ere is a universal access number for citizens to access the EMS/trauma system, with 4. Describe the system-wide policies addressing the dispatch of appropriate medical resources. mode of transport and the type and qualifi cations Th ere is a central communications system of transport personnel used for interfacility for the EMS/trauma system to ensure fi eld- transfers. to-facility bidirectional communications, 5. Specify whether there is a central communications interfacility dialogue, and all-hazards response system to coordinate interfacility transfers. Describe communications among all system participants. how this system has access to information regarding (I-302.7) resource availability within the region. c. Th ere is a procedure for communications among medical facilities when arranging for Documentation Required interfacility transfers, including contingencies Before site visit: for radio or telephone system failure. (I-302.9) ✔ EMS triage criteria for trauma team activation

* Th is section adapted from Health Resources and Services Administration. ✔ Interfacility transfer criteria Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

Trauma System Assurance 21 On-site: Optimal Elements* ✔ Sample copy of an interfacility transfer agreement I. Th e lead agency ensures that adequate rehabilitation facilities have been integrated into ✔ Policy addressing the mode of transport and type the trauma system and that these resources are and qualifi cations of transport personnel used for made available to all populations requiring them. fi eld transport and interfacility transfers (B-308) ✔ Minutes of any meeting documenting ongoing a. Th e lead agency has incorporated, within the quality improvement of transfer criteria trauma system plan and the trauma center ✔ Any policies or procedures related to repatriation standards, requirements for rehabilitation services, including interfacility transfer of trauma patients to rehabilitation centers. (I-308.1) Rehabilitation b. Rehabilitation centers and outpatient Purpose and Rationale rehabilitation services provide data on trauma As an integral component of the trauma system, patients to the central trauma system registry rehabilitation services in acute care and rehabilitation that include fi nal disposition, functional centers provide coordinated care for trauma patients outcome, and rehabilitation costs and also who have sustained severe or catastrophic injuries, participate in performance improvement resulting in long-standing or permanent impairments. processes. (I-308.2) Patients with less severe injuries may also benefi t from II. A resource assessment for the trauma system has rehabilitative programs that enhance recovery and been completed and is regularly updated. (B-103) speed return to function and productivity. Th e goal of rehabilitative interventions is to allow the patient a. Th e trauma system has completed a to return to the highest level of function, reducing comprehensive system status inventory that disability and avoiding handicap whenever possible. identifi es the availability and distribution of Th e rehabilitation process should begin in the acute current capabilities and resources. (I-103.1) care facility as soon as possible, ideally within the Prereview Questionnaire fi rst 24 hours. Inpatient and outpatient rehabilitation 1. Provide data about the number of rehabilitation services should be available. Rehabilitation centers beds and specialty rehabilitation services (SCI, should have CARF (Commission of Accreditation TBI, and pediatric) available within the trauma of Rehabilitation Facilities) accreditation for system’s geographic region. On average, how long comprehensive inpatient rehabilitation programs, and do patients need to wait for these rehabilitation accreditation of specialty centers (SCI and TBI) should beds? Does the average wait vary by type of be strongly encouraged. rehabilitation needed? Th e trauma system should conduct a rehabilitation 2. Describe how existing trauma system policies needs assessment (including specialized programs in and procedures appropriately address treatment SCI, TBI, and for children) to identify the number guidelines for rehabilitation in acute and of beds needed and available for rehabilitation in the rehabilitation facilities. geographic region. Rehabilitation specialists should be integrated into the multidisciplinary advisory 3. Identify the minimum requirements and committee to ensure that rehabilitation issues are qualifi cations that rehabilitation centers have integrated into the trauma system plan. established for physician leaders (for example, medical director of SCI program, medical Th e trauma system should demonstrate strong director of TBI program, and medical director of linkages and transfer agreements between designated rehabilitation program). trauma centers and rehabilitation facilities located in its geographic region (in or out of state). Plans for 4. Describe how rehabilitation specialists are repatriation of patients, especially when rehabilitation integrated into trauma system planning and centers across state lines are used, should be part of advisory groups. rehabilitation system planning. Feedback on functional outcomes after rehabilitation should be made available to the trauma centers. * Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

22 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Documentation Required develop statewide MCI response resource standards. Before site visit: Th is information is essential for the development of an emergency management plan that includes the trauma ✔ A report that specifi es the proportion of patients system. with SCI, TBI (Abbreviated Injury Score for the head ≥3), major trauma (ISS >15), and pediatric Planning and integration of the trauma system with patients (age ≤12 years, ISS >15) with a discharge plans of related systems (public health, EMS, and disposition listed as an inpatient rehabilitation emergency management) are important because of the center extensive impact disasters have on the trauma system and the value of the trauma system in providing care. ✔ A list of the rehabilitation centers and their CARF Relationships and working cooperation between the accreditation status trauma system and public health, EMS, and emergency On-site: management agencies support the provision of assets that enable a more rapid and organized disaster ✔ A list of rehabilitation specialists participating in response when an event occurs. For example, the trauma system planning EMS emergency preparedness plan needs to include ✔ Data pertaining to the number of inpatient beds the distribution of severely injured patients to trauma designated for rehabilitation and staff -to-patient centers, when possible, to make optimal use of trauma ratio center resources. Th is plan could optimize triage through directing less severely injured patients to lower ✔ A list of the rehabilitation data elements that are level trauma centers or nondesignated facilities, thus transferred to the trauma management information allowing resources in trauma centers to be spared for system patients with the most severe injuries. In addition, the ✔ A list of the number of new major trauma, pediatric, trauma system and its trauma centers will be targeted to SCI, and TBI admissions to rehabilitation centers receive additional resources (personnel, equipment, and in the region supplies) during major MCIs. Mass casualty events and disasters are chaotic, and only with planning and drills will a more organized response Disaster Preparedness be possible. Simulation or tabletop drills provide an opportunity to test the emergency preparedness response Purpose and Rationale plans for the trauma system and other systems and to As critically important resources for state, regional, train the teams that will respond. Exercises must be and local responses to MCIs, the trauma system and jointly conducted with other agencies to ensure that all its trauma centers are central to disaster preparedness. aspects of the response plan have the trauma system Trauma system leaders need to be actively involved integrated. in public health preparedness planning to ensure that Optimal Elements* trauma system resources are integrated into the state, I. An assessment of the trauma system’s emergency regional, and local disaster response plans. Acute care preparedness has been completed, including facilities (sometimes including one or more trauma coordination with the public health agency, EMS centers) within an aff ected community are the fi rst line system, and the emergency management agency. of response to an MCI. However, an MCI may result (B-104) in more casualties than the local acute care facilities can handle, requiring the activation of a larger emergency a. Th ere is a resource assessment of the trauma response plan with support provided by state and system’s ability to expand its capacity to regional assets. respond to MCIs in an all-hazards approach. (I-104.1) For this reason, the trauma system and its trauma centers must conduct a resource assessment of its b. Th ere has been a consultation by external surge capacity to respond to MCIs. Th e resource experts to assist in identifying current status assessment should build on and be coupled to a hazard and needs of the trauma system to be able to vulnerability analysis. An assessment of the trauma respond to MCIs. (I-104.2) system’s response to simulated incident or tabletop drills must be conducted to determine the trauma * Th is section adapted from Health Resources and Services Administration. system’s ability to respond to MCIs. Following these Model Trauma System Planning and Evaluation. Rockville, MD: Health assessments, a gap analysis should be conducted to Resources and Services Administration; 2006.

Trauma System Assurance 23 c. Th e trauma system has completed a gap agencies (trauma system, EMS, public health, analysis based on the resource assessment for emergency management) trauma emergency preparedness. (I-104.3) On-site: II. Th e lead agency ensures that its trauma system ✔ A sample of minutes from joint agency emergency plan is integrated with, and complementary to, management planning meetings from the past year the comprehensive mass casualty plan for natural and manmade incidents, including an all-hazards ✔ After-action report of jointly conducted (multiple approach to planning and operations. (B-305) emergency management agencies) simulated or tabletop drills that include the trauma system’s a. Th e EMS, the trauma system, and the capability to respond to MCIs all-hazards medical response system have operational trauma and all-hazards response plans and have established an ongoing cooperative working relationship to ensure System-wide Evaluation trauma system readiness for all-hazards events. and Quality Assurance (I-305.1) Purpose and Rationale b. All-hazards events routinely include situations involving natural (for example, earthquake), Th e trauma lead agency has responsibility for unintentional (for example, school bus instituting processes to evaluate the performance of all crash), and intentional (for example, terrorist aspects of the trauma system. Key aspects of system- explosion) trauma-producing events that test wide eff ectiveness include the outcomes of population- the expanded response capabilities and surge based injury prevention initiatives, access to care, as capacity of the trauma system. (I-305-2) well as the availability of services, the quality of services provided within the trauma care continuum from c. Th e trauma system, through the lead agency, prehospital and acute care management phases through has access to additional equipment, materials, rehabilitation and community reintegration, and and personnel for large-scale traumatic events. fi nancial impact or cost. Intrinsic to this function is the (I-305.3) delineation of valid, objective metrics for the ongoing Prereview Questionnaire quality audit of system performance and patient outcomes based on sound benchmarks and available 1. When was the last assessment of trauma system clinical evidence. Trauma management information preparedness resources conducted, and what were systems (MISs) must be available to support data the signifi cant fi ndings of the assessment as they collection and analysis. relate to emergency preparedness? Th e lead agency should establish forums that promote 2. What actions were taken to remediate or mitigate inclusive multidisciplinary and multiagency review the gaps identifi ed through tabletop or simulated of cases, events, concerns, regulatory issues, policies, responses in disaster drills among the acute care procedures, and standards that pertain to the trauma facilities participating in the system? system. Th e evaluation of system eff ectiveness must 3. What is the trauma system plan to accommodate take into account the integration of these various a need for a surge in personnel, equipment, and components of the trauma care continuum and review supplies? how well personnel, agencies, and facilities perform together to achieve the desired goals and objectives. 4. How is the trauma system integrated into the Results of customer satisfaction (patient, provider, and state’s incident command system and the facility) appraisals and data indicative of community communications center? and population needs should be considered in 5. What strategies and mechanisms are in place to strategic planning for system development. System ensure adequate interhospital communication improvements derived through evaluation and quality during an MCI? assurance activities may encompass enhancements in technology, legislative or regulatory infrastructure, Documentation Required clinical care, and critical resource availability. Before site visit: To promote participation and sustainability, the lead ✔ An organizational chart identifying the agency should associate accountability for achieving relationships among key emergency management defi ned goals and trauma system performance

24 Regional Trauma Systems: Optimal Elements, Integration, and Assessment indicators with meaningful incentives that will act to b. How does it decide what parameters to monitor? cement the support of key constituents in the health c. What action is it empowered to take to care community and general population. For example, improve trauma care? the costs and benefi ts of the trauma system as they relate to reducing mortality or decreasing years of 2. Describe the trauma system performance productive life lost may make the value of promoting improvement eff orts as they pertain to the system trauma system development more tangible. A facility for the following groups of providers in the context that achieves trauma center verifi cation/designation of system integration: may be rewarded with monetary compensation (for a. Dispatch centers example, ability to bill for trauma activation fees) and the ability to serve as a receiving center for trauma b. Prehospital provider agencies patients. Th e trauma lead agency should promote c. Trauma centers ongoing dialog with key stakeholders to ensure that incentives remain aligned with system needs. d. Other acute care and specialty facilities Optimal Elements* e. Rehabilitation centers I. Th e trauma MIS is used to facilitate ongoing 3. List the process and patient outcome measures that assessment and assurance of system performance are tracked at the trauma system level, including and outcomes and provides a basis for measures for special populations. continuously improving the trauma system, including a cost-benefi t analysis. (B-301) 4. As part of your system-wide performance improvement, specify whether each of the a. Th e lead trauma authority ensures that each following is assessed on a regular basis: member hospital of the trauma system collects and uses patient data, as well as provider data, a. Time from arrival to a center and ultimate to assess system performance and to improve discharge to a facility capable of providing quality of care. Assessment data are routinely defi nitive care. If yes, specify the mean time submitted to the lead trauma authority. (I-301.1) to transfer. II. Th e jurisdictional lead agency, in cooperation with b. Proportion of patients with injury more severe other agencies and organizations, uses analytic than a predefi ned injury severity threshold (for tools to monitor the performance of population- example, ISS >15, or other criteria) who receive based prevention and trauma care services. (B-304) defi nitive care at a facility other than a Level I or II trauma center (undertriage) III. Th e fi nancial aspects of the trauma system are integrated into the overall performance c. Proportion of patients with injury less severe improvement system to ensure ongoing fi ne- than a predefi ned injury severity threshold (for tuning and cost-eff ectiveness. (B-309) example, ISS <9) who are transferred from any facility to a Level I or II trauma center a. Financial data are combined with other cost, (overtriage) outcome, or surrogate measures, for example, years of potential life lost, quality-adjusted 5. Describe how your system addresses problems life years, and disability-adjusted life years; related to signifi cant overtriage or undertriage, length of stay; length of intensive care unit both primary and secondary. stay; number of ventilator days; and others, to Documentation Required estimate and track true system costs and cost- Before site visit: benefi ts. (I-309.4) ✔ List of the agencies represented on the committee Prereview Questionnaire responsible for trauma system quality assurance 1. What is the membership of the committee charged with ongoing monitoring and evaluating of the On-site: trauma system? ✔ Trauma system annual reports and fact sheets for a. To whom does it report its fi ndings? the past 2 years ✔ A copy of minutes or meeting notes pertaining to * Th is section adapted from Health Resources and Services Administration. the identifi cation, discussion, and resolution of a Model Trauma System Planning and Evaluation. Rockville, MD: Health trauma system (rather than a trauma center) issue. Resources and Services Administration; 2006.

Trauma System Assurance 25 designated as trauma centers allows one to evaluate Trauma Management systems issues only among patients transported to Information Systems appropriate facilities. It is also important to have protocols in place to ensure a uniform approach to data Purpose and Rationale abstraction and collection. Research suggests that if the Hospital-based trauma registries developed from the process of case abstraction is not routinely calibrated, idea that aggregating data from similar cases may practices used by abstractors begin to drift. reveal variations in care and ultimately result in a better understanding of the underlying injury and Finally, every eff ort should be made to conform its treatment. Hospital-based registries have proven to national standards defi ning processes for case very eff ective in improving trauma care within an acquisition, case defi nition (that is, inclusion criteria), institution but provide limited information regarding and registry coding conventions. Two such national how interactions with other phases of health care standards include the National Highway Traffi c Safety infl uence the outcome of an injured patient. To address Administration’s National Emergency Medical Services this limitation, data from hospital-based registries Information System (NEMSIS), which standardizes should be collated into a regional registry and linked EMS data collection, and the American College of such that data from all phases of care (prehospital, Surgeons National Trauma Data Standard, which hospital, and rehabilitation) are accessible in 1 data set. addresses the standardization of hospital registry data When possible, these data should be further linked to collection. Strictly adhering to national standards law enforcement, crash incident reports, ED records, markedly increases the value of state trauma MISs by administrative discharge data, medical examiner providing national benchmarks and allowing for the records, vital statistics data (death certifi cates), and use of software solutions that link data sets to enable a fi nancial data. Th e information system should be review of the entire injury and health care event for an designed to provide system-wide data that allow and injured patient. facilitate evaluation of the structure, process, and To derive value from the tremendous amount of eff ort outcomes of the entire system; all phases of care; and that goes into data collection, it is important that a their interactions. Th is information should be used to similar focus address the process of data reporting. develop, implement, and infl uence public policy. Dedicated staff and resources should be available to Th e lead agency should maintain oversight of the ensure rapid and consistent reporting of information information system. In doing so, it must defi ne the to vested parties with the authority and vision to roles and responsibilities for agencies and institutions prevent injuries and improve the care of patients with regarding data collection and outline processes to injuries. An optimal information reporting process will evaluate the quality, timeliness, and completeness of include standardized reporting tools that allow for the data. Th ere must be some means to ensure patient assessment of temporal and/or system changes and a and provider confi dentiality is in keeping with federal dynamic reporting tool, permitting anyone to tailor regulations. Th e agency must also develop policies and specifi c “views” of the information. procedures to facilitate and encourage injury surveillance Optimal Elements* and trauma care research using data derived from the trauma MIS. I. Th ere is an established trauma MIS for ongoing injury surveillance and system performance Th ere are key features of regional trauma MISs that assessment. (B-102) enhance their usefulness as a means to evaluate the quality of care provided within a system. Patient a. Th ere is an established injury surveillance information collected within the management system process that can, in part, be used as an MIS must be standardized to ensure that noted variations performance measure. (I-102.1) in care can be characterized in a similar manner across b. Injury surveillance is coordinated with diff ering geographic regions, facilities, and EMS statewide and local community health agencies. Th e composition of patients and injuries surveillance. (I-102.2) included in local registries (inclusion criteria) should be consistent across centers, allowing for the evaluation c. Th ere is a process to evaluate the quality, of processes and outcomes among similar patient timeliness, completeness, and confi dentiality groups. Many regions limit their information systems of data. (I-102.4) to trauma centers. However, the optimal approach is * Th is section adapted from Health Resources and Services Administration. to collect data from all acute care facilities within the Model Trauma System Planning and Evaluation. Rockville, MD: Health region. Limiting required data submission to hospitals Resources and Services Administration; 2006.

26 Regional Trauma Systems: Optimal Elements, Integration, and Assessment d. Th ere is an established method of collecting e. Hospital records (hospital trauma registries) trauma fi nancial data from all health care f. Hospital administrative discharge data facilities and trauma agencies, including patient charges and administrative and system costs. g. Rehabilitation data (I-102.5) h. Coroner and medical examiner records II. Th e trauma MIS is used to facilitate ongoing i. Financial or payer data assessment and assurance of system performance and outcomes and provides a basis for j. Dispatch continuously improving the trauma system, 3. What are the regional trauma registry inclusion including a cost-benefi t analysis. (B-301) criteria? a. Th e lead trauma authority ensures that each 4. Which stakeholders had a role in selecting the data member hospital of the trauma system collects elements for inclusion into the regional registry? and uses patient data, as well as provider data, to assess system performance and to improve a. From what source(s) were the data fi eld quality of care. Assessment data are routinely defi nitions derived? submitted to the lead trauma authority. b. What pediatric data elements are captured? (I-301.1) 5. What local or system-wide reports are routinely b. Prehospital care providers collect patient care generated and at what frequency? and administrative data for each episode of care and not only provide these data to the hospital, 6. Are data contributed to the National Trauma Data but also have a mechanism to evaluate the data Bank (NTDB) or other outside agencies? If so, within their own agency, including monitoring please specify which agencies. trends and identifying outliers. (I-301.2) Documentation Required c. Trauma registry, ED, prehospital, rehabilitation, Before site visit: and other databases are linked or combined to create a trauma system registry. (I-301.3) ✔ Policies and procedures related to release of data d. Th e lead agency has available for use the latest On-site: in computer/technology advances and analytic ✔ Data dictionary for the trauma registry tools for monitoring injury prevention and control components of the trauma system. ✔ A typical regional registry report, redacted to Th ere is reporting on the outcome of maintain confi dentiality implemented strategies for injury prevention and control programs within the trauma system. (I-301.4) Research Prereview Questionnaire Purpose and Rationale 1. Which agency has oversight of the trauma MIS? Overview of Research Activity a. Describe the role and responsibilities of the lead agency in collecting and maintaining the data. Trauma systems are remarkably diverse. Th is diversity is simply a refl ection of authorities tailoring the system b. How are the completeness, timeliness, and to meet the needs of the region based on the unique quality of the data monitored? combination of geographic, economic, and population 2. Specify which of the following data sources are characteristics within their jurisdiction. In addition, linked to the information system. Describe the trauma systems are not fi xed in their organization or method of linkage (for example, probabilistic or operation. Th e system evolves over years in response deterministic). to lessons learned, critical review, and changes in population demographics. Given the diversity of a. Motor-vehicle crash or incident data organization and the dynamic nature of any particular b. Law enforcement records system, it is valuable when research can be conducted that evaluates the eff ectiveness of the regional or c. EMS or other transporting agency records statewide system. Research drives the system and will d. ED records provide the foundation for system development and

Trauma System Assurance 27 performance improvement. Research fi ndings provide that includes approval by an authorized institutional value in defi ning best practices and might alter system review board. Trauma registry data may include unique development. Th us, the system should facilitate and identifi ers, and system administrators must ensure that encourage trauma-related research through processes patient confi dentiality is respected, consistent with state designed to make data available to investigators. and federal regulations. Competitive grants or contracts made available through lead authorities or constituencies should provide funds Population-based Trauma System Research to support research activities. All system components A major disadvantage of using only trauma registry should contribute to the research agenda. Th e extent to data to conduct research that evaluates injured patients which research activities are required should be clearly in a region is the bias resulting from missing data on outlined in the trauma system plan and/or the criteria patients not treated at trauma centers. Specifi cally, most for trauma center designation. registry data are restricted to information from hospitals that participate in the trauma system. Although ideally Th e sources of data used for research might be all facilities participate in the form of an inclusive institutional and regional trauma registries. As an system, many systems do not attain this goal. Th us, alternative, population-based research might provide a a population-based data set provides investigators broader view of trauma care within the region. Primary with the full spectrum of patients, irrespective of data collection, although desirable, is expensive but whether they have been treated in trauma centers might provide insights into system performance that or nondesignated centers or were never admitted to might not be otherwise available. the hospital owing to death at the scene of incident Trauma Registry–based Research or because their injuries were insuffi ciently severe to require admission. Th e state and national hospital Investigators examining trauma systems can use the discharge databases are examples of population-based information recorded in trauma registries to great data. Th ese discharge databases contain information advantage to determine the prevalence and annual that was abstracted from medical records for billing incidence rate of injuries, patterns of care that occur to purposes by hospital employees who enter these data injured patients in the system’s region, and outcomes into an electronic database. For investigators seeking for the patients. Th ese data can be compared with a wider perspective on the care of injured patients in standards available from other trauma registries, such their region, these more inclusive data sets, compared as the NTDB. Such comparisons can then enable with registries, are essential tools. Other population- investigators to determine if care within their region is based data that may be of help include mortality vital within standards and can allow for benchmarking. statistics data recorded in death certifi cates. Selected Initiating and sustaining injury prevention initiatives regions might have outpatient data to capture patients is a vital goal in mature trauma systems. Investigators who are assessed in the ED and then released. can take a leadership role in performing research using Investigators can use these population-based data to trauma registry data that identify emerging threats study the infl uence of a regional trauma system on the and instituting public health measures to mitigate entire spectrum of patients within its catchment area. the threats. For example, a recent surge in death and disability related to off -road vehicles can be identifi ed Participation in Research Projects and the scope of the problem defi ned in terms of who, and Primary Data Collection where, and how riders are injured, and then, through Multi-institutional research projects are important presentations and publications, the public can be mechanisms for learning new knowledge that can guide informed of a new threat. the care of injured patients. Investigators within trauma Trauma system administrators have a responsibility to systems can participate as coinvestigators in these control investigators’ access to the registry. Th e integrity projects. Investigators can participate by recruiting and reliability of data in a trauma systems registry are patients into prospective studies, being leaders in the essential if accurate research and valid conclusions design and administration of grants, and preparing are to be reached using the data. Trauma system manuscripts and reports. Evidence of this collaboration administrators should have a process that screens data is that investigators within a trauma system are entered into the system’s composite registry from recognized in announcements of grants or awards. individual institutions. Th ere should be a mechanism Lead agency personnel should identify and reach out that ensures that the information is stored in a secure to resources within the system with research expertise. manner. Investigators who seek access to the trauma Th ese include academic centers and public health registry must follow a written policy and procedure agencies.

28 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Measures of Research Activity trauma care as measured by patient outcomes. Research can be broadly defi ned as hypothesis-driven (B-307) data analysis. Th is analysis leads the investigators to a a. Th e trauma system implements and regularly conclusion, which might become a recommendation reviews a standardized report on patient care for system change. Full manuscripts published in peer- outcomes as measured against national norms. reviewed research journals are an exemplary form of research activity. Research reported in annual reviews Prereview Questionnaire or in public information formats intended to inform 1. Describe the current procedures and processes the trauma system’s constituency can also be considered investigators must follow to request access to the legitimate research activity. trauma system registry. Optimal Elements* 2. What are the mechanisms used to ensure patient I. Th e trauma MIS is used to facilitate ongoing confi dentiality when regional trauma registry data assessment and assurance of system performance are used by investigators? and outcomes and provides a basis for continuously 3. Provide examples of where research was conducted improving the trauma system, including a cost- for the purpose of providing evidence that the benefi t analysis. (B-301) processes of care and outcome of injured patients a. Th e lead agency has available for use the latest in the system’s region are within acceptable in computer/technology advances and analytic standards. tools for monitoring injury prevention and 4. How has research been used to modify policy or control components of the trauma system. practice within the system? Th ere is reporting on the outcome of implemented strategies for injury prevention 5. What resources (for example, personnel and and control programs within the trauma fi scal) are available to the lead agency to assist in system. (I-301.4) conducting system research? II. Th e lead agency ensures that the trauma system Documentation Required demonstrates prevention and medical outreach Before site visit: activities within its defi ned service area. (B-306) ✔ No additional documentation required a. Th e trauma system has developed mechanisms to engage the general medical community On-site: and other system participants in their research ✔ Policies and procedures pertaining to data access fi ndings and performance improvement eff orts. for research purposes (I-306.1) ✔ A bibliography of research publications published b. Th e eff ect or impact of outreach programs by investigators in the system (medical community training/support and ✔ prevention activities) is evaluated as part of a A list of data requests for the regional trauma system performance improvement process. registry for the past year III. To maintain its state, regional, or local designation, each hospital will continually work to improve the

* Th is section adapted from Health Resources and Services Administration. Model Trauma System Planning and Evaluation. Rockville, MD: Health Resources and Services Administration; 2006.

Trauma System Assurance 29

SECTION 4 P M

POSTCONSULTATION MEASURES 0 Not known Postconsultation follow-up involves 2 aspects. Th e fi rst is the 1 Th ere is no written description of injuries within degree to which the state or region has done the following: the trauma system jurisdiction. • Prioritized the recommendations contained in the fi nal 2 One or more population-based data sources (for report from the trauma systems consultation process example, vital statistics and medical examiner data) • Developed an action plan using a logic model or other describe injury within the jurisdiction, but clinical framework that identifi es the outputs and outcome data sources are not used. measures of achieving the prioritized recommendations 3 One or more population-based data sources and • Made progress in achieving the steps in the action plan one or more clinical data sources are used to describe injury within the jurisdiction. Th e second is an ongoing repeated measures process using the benchmarks, indicators, and scoring process 4 Multiple population-based and clinical data identifi ed in the Model Trauma System Planning and sources are used to describe injury within the Evaluation document. Th e following indicators are seen as jurisdiction, and the description is systematically representative measures of assessment, policy development, updated at regular intervals. and assurance issues. Repeated measures of these indicators, 5 Multiple population-based and clinical data over time, will serve as 1 mark of progress in strengthening sources (for example, trauma registry, ED data, the trauma system. and others) are electronically linked and used to describe injury within the jurisdiction.

102.2 Injury surveillance is coordinated with statewide Indicators of Trauma System and local community health surveillance. Development Status 0 Not known Assessment 1 Injury surveillance, as described in 102.1, does not 101.2 Th ere is a description of injuries within the occur within the system. trauma system jurisdiction including the distribution by geographic area, high-risk populations (pediatric, 2 Injury surveillance occurs in isolation from other elderly, distinct cultural/ethnic, rural, and others), inci- health risk surveillance and is reported separately. dence, prevalence, mechanism, manner, intent, mortality, 3 Injury surveillance occurs in isolation but is contributing factors, determinants, morbidity, injury combined and reported with other health risk severity (including death), and patient distribution surveillance processes. using any or all of the following: vital statistics, emergency department (ED) data, emergency medical 4 Injury surveillance occurs as part of broader health services (EMS) data, hospital discharge data, state police risk assessments. data (data from law enforcement agencies), medical 5 Processes of sharing and linkage of data exist examiner data, and trauma registry and other data among EMS systems, public health systems, and sources. Th e description is updated at regular intervals. trauma systems, and the data are used to monitor, Note: Injury severity should be determined through the investigate, and diagnose community health risks. consistent and system-wide application of one of the existing injury scoring methods, for example, Injury 102.3 Trauma data are electronically linked from a Severity Score (ISS). variety of sources.

Postconsultation Measures 31 Note: Deterministically means with such patient identifi ers 4 Th e authority exists to fully develop all operational as name and date of birth. Probabilistically means guidelines and standards; the stakeholders computer software is used to match likely records through are reviewing draft policies and procedures; less certain identifi ers such as date of incident, patient age, and adoption by the lead agency, including gender, and others. implementation and enforcement, is pending. 0 Not known 5 Th e authority exists; operational policies and procedures and trauma system performance 1 Trauma registry data exist but are not standards are in place; and compliance is being deterministically or probabilistically linked to actively monitored. other databases. 2 Trauma registry data exist and can be 203.1 Th e lead agency, in concert with a trauma- deterministically linked through hand-sorting specifi c multidisciplinary, multiagency advisory processes. committee, has adopted a trauma system plan. 3 Trauma registry data exist and can be 0 Not known deterministically linked through computer- 1 Th ere is no trauma system plan, and one is not in matching processes. progress. 4 Trauma registry data exist and can be 2 Th ere is no trauma system plan, although some deterministically and probabilistically linked to groups have begun meeting to discuss the at least one other injury database including: EMS development of a trauma system plan. data systems (that is, patient care records, dispatch data, and others), ED data systems, hospital 3 A trauma system plan was developed and adopted discharge data, and others. by the lead agency. Th e plan, however, has not been endorsed by trauma stakeholders. 5 All data stakeholders (insurance carriers, FARS, and rehabilitation, in addition to typical trauma 4 A trauma system plan has been adopted, developed system resources) have been identifi ed, data access with multiagency groups, and endorsed by those agreements executed, hardware and software agencies. resources secured, and the “manpower” designated 5 A comprehensive trauma system plan has been to deterministically and probabilistically link, developed, adopted in conjunction with trauma analyze, and report a variety of data sources in a stakeholders, and includes the integration of other timely manner. systems (for example, EMS, public health, and emergency preparedness). Policy Development 201.4 Th e lead agency has adopted clearly defi ned 203.4 Th e trauma system plan clearly describes the trauma system standards (for example, facility system design (including the components necessary to standards, triage and transfer guidelines, and data have an integrated and inclusive trauma system) and is collection standards) and has suffi cient legal authority used to guide system implementation and management. to ensure and enforce compliance. For example, the plan includes references to regulatory 0 Not known standards and documents and includes methods of data collection and analysis. 1 Th e lead agency does not have suffi cient legal authority and has not adopted or defi ned trauma 0 Not known system performance and operating standards, nor 1 Th ere is no trauma system plan. is there suffi cient legal authority to do so. 2 Th e trauma system plan does not address or 2 Suffi cient authority exists to defi ne and adopt incorporate the trauma system components standards for trauma system performance and (prehospital, communication, transportation, acute operations, but the lead agency has not yet care, rehabilitation, and others), nor is it inclusive completed this process. of all-hazards preparedness, EMS, or public health 3 Th ere is suffi cient legal authority to adopt and integration. implement operation and performance standards 3 Th e trauma system plan provides general including enforcement. Draft process procedures information about all the components including have been developed. all-hazards preparedness, EMS, and public health

32 Regional Trauma Systems: Optimal Elements, Integration, and Assessment integration; however, it is diffi cult to determine 204.3 Designated funding for trauma system who is responsible and accountable for system infrastructure support (lead agency) is legislatively performance and implementation. appropriated. 4 Th e trauma system plan addresses every Note: Although nomenclature concerning designated, component of a well-organized and functioning appropriated, and general funds varies between trauma system including all-hazards preparedness jurisdictions, the intent of this indicator is to demonstrate and public health integration. Specifi c information long-term, stable funding for trauma system development, on each component is provided, and trauma management, evaluation, and improvement. system design is inclusive of providing for specifi c 0 Not known goals and objectives for system performance. 1 Th ere is no designated funding to support the 5 Th e trauma system plan is used to guide system trauma system infrastructure. implementation and management. Stakeholders and policy leaders are familiar with the plan and its 2 One-time funding has been designated for trauma components and use the plan to monitor system system infrastructure support, and appropriations progress and to measure results. have been made to the lead agency budget. 3 Limited funds for trauma system development 204.2 Financial resources exist that support the have been identifi ed, but the funds have not been planning, implementation, and ongoing management appropriated for trauma system infrastructure of the administrative and clinical care components of support. the trauma system. 4 Consistent, though limited, infrastructure funding 0 Not known has been designated and appropriated to the lead 1 Th ere is no funding to support the trauma agency budget. system planning, implementation, or ongoing 5 Th e legislature has identifi ed, designated, and management and operations for either trauma appropriated suffi cient infrastructure funding for system administration or trauma clinical care. the lead agency consistent with the trauma system 2 Some funding for trauma care within the third- plan and priorities for funding administration and party reimbursement structure has been identifi ed, operations. but ongoing support for administration and clinical care outside the third-party reimbursement 208.1 Th e trauma system and the public health structure is not available. system have established linkages including programs with an emphasis on population-based public health 3 Th ere is current funding for the development surveillance and evaluation for acute and chronic of the trauma system within the lead agency traumatic injury and injury prevention. organization consistent with the trauma system plan, but costs to support clinical care support 0 Not known services have not been identifi ed (transportation, 1 Th ere is no evidence that demonstrates program communication, uncompensated care, standby linkages, a working relationship, or the sharing fees, and others). No ongoing commitment of of data between the public health system and the funding has been secured. trauma system. Population-based public health 4 Th ere is funding available for both administrative surveillance and evaluation for acute or chronic and clinical components of the trauma system traumatic injury and injury prevention have not plan. A mechanism to assess needs among various been integrated with the trauma system. providers has begun. Implementation costs and 2 Th ere is little population-based public health ongoing support costs of the lead agency have been surveillance shared with the trauma system, and addressed within the plan. program linkages are rare. Routine public health 5 A stable (consistent) source of reliable funding for status reports are available for review by the trauma the development, operations, and management system lead agency and constituents. of the trauma program (clinical care and lead 3 Th e trauma system and the public health system agency administration) has been identifi ed have begun sharing public health surveillance data and is being used to support trauma planning, for acute and chronic traumatic injury. Program implementation, maintenance, and ongoing linkages are in the discussion stage. program enhancements.

Postconsultation Measures 33 4 Th e trauma system has begun to link with the 0 Not known public health system, and the process of sharing 1 Th ere is no medical oversight for EMS providers public health surveillance data is evolving. Routine within the trauma system. dialogue is occurring between programs. 2 EMS medical oversight for all levels of prehospital 5 Th e trauma system and the public health system providers caring for the trauma patient is provided, are integrated. Routine reporting, program but such oversight is provided outside of the participation, and system plans are fully vested. purview of the trauma system. Operational integration is routine, and measurable progress can be demonstrated. (Demonstrated 3 Th e EMS and trauma medical directors have integration and linkage could include such integrated prehospital medical oversight for activities as rapid response to and notifi cation of prehospital personnel caring for trauma patients. incidents, integrated data systems, communication 4 Medical oversight is routinely given to EMS cross-operability, and regular epidemiology report providers caring for trauma patients. Th e trauma generation.) system has integrated medical oversight for prehospital providers and routinely evaluates the Assurance eff ectiveness of both online and off -line medical 301.1 Th e lead trauma authority ensures that each oversight. member hospital of the trauma system collects and uses patient data as well as provider data to assess system 5 Th e EMS and trauma system fully integrate the performance and to improve quality of care. Assessment most up-to-date medical oversight and regularly data are routinely submitted to the lead trauma evaluate program eff ectiveness. System providers authority. are included in the development of medical oversight policies. 0 Not known 1 Th ere is no system-wide management information 302.6 Th ere are mandatory system-wide prehospital data collection system that the trauma centers and triage criteria to ensure that trauma patients are other community hospitals regularly contribute to transported to an appropriate facility based on their or use to evaluate the system. injuries. Th ese triage criteria are regularly evaluated and updated to ensure acceptable and system-defi ned 2 Th ere is a trauma registry system in place in rates of sensitivity and specifi city for appropriately the trauma centers, but it is used by neither all identifying major trauma patients. facilities within the system nor the lead trauma authority to assess system performance. 0 Not known 3 Th e trauma management information system 1 Th ere are no mandatory universal triage criteria to contains information from all facilities within a ensure trauma patients are transported to the most geographic area. appropriate hospital. 4 Th e trauma management information system is 2 Th ere are diff ering triage criteria guidelines used used by the trauma centers to assess provider and by diff erent providers. Appropriateness of triage system performance issues. criteria and subsequent transportation are not evaluated for sensitivity or specifi city. 5 Hospital trauma registry data are routinely submitted to the lead trauma authority, are 3 Universal triage criteria are in the process of being aggregated, and are used to evaluate overall system linked to the management information system for performance. future evaluation. 4 Th e triage criteria are used by all prehospital 302.1 Th ere is well-defi ned trauma system medical providers. Th ere is system-wide evaluation of oversight integrating the specialty needs of the trauma the eff ectiveness of the triage tools in identifying system with the medical oversight for the overall EMS trauma patients and in ensuring that they are system. transported to the appropriate facility. Note: Th e EMS System medical director and the trauma 5 System participants routinely evaluate the triage medical director may, in fact, be the same person. criteria for eff ectiveness. Th ere is linkage with the trauma system, and sensitivity and specifi city

34 Regional Trauma Systems: Optimal Elements, Integration, and Assessment (over- and under-triage rates) of the tools used 4 Review of trauma care quality is both internal are regularly reported through the trauma lead (through routine monitoring and evaluation) and authority. Updates to the triage criteria are made as external (through independent review during necessary to improve system performance. redesignation or reverifi cation of trauma centers). 5 Quality of trauma care is ensured through both 303.1 Th e trauma system plan has clearly defi ned internal and external methods. Internal review is the roles and responsibilities of all acute care facilities regular, and participation is routine for trauma treating trauma and of facilities that provide care to stakeholders. External independent review teams specialty populations (for example, burn, pediatric, provide further assurance of quality trauma care spinal cord injury, and others). within all licensed acute care and trauma facilities 0 Not known treating trauma patients. 1 Th ere is no trauma system plan that outlines 308.1 Th e lead agency has incorporated, within the roles and responsibilities of all acute care facilities trauma system plan and the trauma center standards, treating trauma and of facilities that provide care requirements for rehabilitation services including to special populations. interfacility transfer of trauma patients to rehabilitation 2 Th ere is a trauma system plan, but it does not centers. address the roles and responsibilities of licensed 0 Not known acute care and specialty care facilities. 1 Th ere are no written standards or plans for the 3 Th e trauma system plan addresses the roles and integration of rehabilitation services with the responsibilities of licensed acute care facilities or trauma system or with trauma centers. specialty care facilities, but not both. 2 Th e trauma system plan has incorporated the use 4 Th e trauma system plan addresses the roles and of rehabilitation services, but the use of those responsibilities of licensed acute care facilities and facilities for trauma patients has not been fully specialty care facilities. realized. 5 Th e trauma system plan clearly defi nes the roles 3 Th e trauma system plan has incorporated and responsibilities of all acute care facilities requirements for rehabilitation services. Th e treating trauma within the system jurisdiction. trauma centers routinely use the rehabilitation Specialty care services are addressed within the expertise although written agreements do not exist. plan, and appropriate policies and procedures are implemented and tracked. 4 Th e trauma system plan incorporates rehabilitation services throughout the continuum 307.1 Th e trauma system engages in regular evaluation of care. Trauma centers have actively included of all licensed acute care facilities that provide trauma rehabilitation services and their programs in care to trauma patients and of designated trauma trauma patient care plans. hospitals. Such evaluation involves independent 5 Th ere is evidence to show a well-integrated external reviews. program of rehabilitation is available for all trauma 0 Not known patients. Rehabilitation programs are included in the trauma system plan, and the trauma centers 1 Th ere is no ongoing mechanism for the trauma work closely with rehabilitation centers and system to assess or evaluate the quality of trauma services to ensure quality outcomes for trauma care delivered by all licensed acute care facilities patients. that provide trauma care to trauma patients and of designated trauma hospitals. 311.4 Laws, rules, and regulations are routinely 2 Th ere is a mechanism for the trauma system reviewed and revised to continually strengthen and to evaluate trauma care services in designated improve the trauma system. trauma hospitals through internal performance 0 Not known improvement processes. 1 Th ere is no process for examining laws, rules, or 3 Th ere is a mechanism to evaluate trauma care regulations. services across the entire trauma care system through performance improvement processes.

Postconsultation Measures 35 2 Laws, rules, and regulations are reviewed and 5 Laws, rules, and regulations are reviewed as revised only in response to a “crisis” (for example, part of the performance improvement process malpractice insurance costs). involving representatives of all system components and are revised as they negatively impact system 3 Laws, rules, and regulations are reviewed and performance. revised on a periodic schedule (for example, every 5 years). 4 Laws, rules, and regulations are reviewed by agency per sonnel on a continuous basis and are revised as needed.

36 Regional Trauma Systems: Optimal Elements, Integration, and Assessment

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40 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Rogers FB, Madsen L, Shackford S, et al. A needs Sihler KC, Hansen AR, Torner JC, et al. Characteristics assessment for regionalization of trauma care in a of twice-transferred, rural trauma patients. rural state. Am Surg. 2005; 71:690–693. Prehospital Emerg Care. 2002; 6:330–335. Rogers FB, Shackford SR, Hoyt DB, et al. Trauma Simons R, Kasic S, Kirkpatrick A, et al. Relative deaths in a mature urban vs rural trauma system. importance of designation and accreditation of Arch Surg. 1997; 132:376–382. trauma centers during evolution of a regional trauma system. J Trauma. 2002; 52:827–834. Rosemurgy AS, Norris PA, Olson SM, et al. Prehospital traumatic arrest: the cost of futility. J Trauma. Southhard PA, Hedges JR, Hunger JG, et al. Impact 1993; 35:468–473. of a transfer center on interhospital referrals and transfers to a tertiary care center. Acad Emerg Med. Rosenberg L. Th e physician-scientist: an essential—and 2005; 12:653–657. fragile—link in the medical research chain. J Clin Invest. 1999; 103:1621–1626. Stratton SJ, Brickett K, Crammer T. Prehospital pulseless, unconscious penetrating trauma victims: Runyan CW. Using the Haddon matrix: introducing fi eld assessments associated with survival. J Trauma. the third dimension. Injury Prev. 1998; 4:302–307. 1998; 45:96–100. Rutledge R, Fakhry SM, Baker CC, et al. A population- Taheri, PA, Butz, DA, Lottenberg, L, et al. Th e cost of based study of the association of medical trauma center readiness. Am J Surg. 2004; 187: manpower with county trauma death rates in the 7–13. United States. Ann Surg. 1994; 219:547–563. Tellez MG, Mackersie RC, Morabito D, et al. Risks, Rutledge R, Messick J, Baker CC, et al. Multivariate costs and the expected complication of re-injury. population-based analysis of the association of Am J Surg. 1995; 170:660–663. county trauma centers with per capita county trauma death rates. J Trauma. 1992; 33:29–38. Trauma-Emergency Medical Services System Survey. 2003. US Department of Health and Sampalis JS, Lavoie A, Boukas S, et al. Trauma center Human Services, Health Resources and Services designation: initial impact on trauma-related Administration. Available at: www.hrsa.gov/ mortality. J Trauma. 1995; 39:232–239. TRAUMA/survey/default.htm. Accessed March 3, Schermer CR, Qualis CR, Brown CL, et al. Intoxicated 2006. motor vehicle passengers: an overlooked at-risk US Department of Health and Human Services, Health population. Arch Surg. 2001; 136:1244–1248. Resources and Services Administration, Trauma- Sciortino S, Vassar M, Radetsky M, et al. San Francisco EMS Systems Program. Model Trauma Systems pedestrian injury surveillance: mapping, under- Planning and Evaluation. 2006. Available at: www. reporting, and injury severity in police and hospital hrsa.gov/trauma/model.htm. Accessed February records. Accid Anal Prev. 2005; 37:1102–1113. 2006. Segui-Gomez M, Chang DC, Paidas CN, et al. Van Olden GD, Meeuwis JD, Vohuis HW, et al. Pediatric trauma care: an overview of pediatric Clinical impact of advanced trauma life support. trauma systems and their practices in 18 US states. Am J Emerg Med. 2004; 22:522–525. J Pediatr Surg. 2003; 38:1162–1169. Waeckerle JF. Disaster planning and response. N Engl Selzer D. Public hospital–based level I trauma centers: J Med. 1991; 324:815–821. fi nancial survival in the new millennium. J Trauma. Wells S. Th e surgical scientist. Ann Surg. 1996; 224: 2001; 51:301–307. 239–254. Shackford SR, Hollingsworth-Fridlund P, McArdle West JG, Trunkey DD, Lim RC. Systems of trauma M, et al. Assuring quality in a trauma system: the care: a study of two counties. Arch Surg. 1979; medical audit committee: composition, cost, and 114:455–460. results. J Trauma. 1987; 27:866–875. West JG, Williams MJ, Trunkey DD, et al. Trauma Shinowara N. Who’d want to work in a team? Nature. systems: current status: future challenges. JAMA. 2003; 424:1–5. 1988; 259:3597–3600.

Suggested Reading 41

APPENDIX A G  T, A,  A

Glossary of Terms setting to rehabilitation services and follow-up care. Such systems include data systems for injury Agency A division of government with a specifi c surveillance and prevention and for performance function off ering a particular kind of assistance. measurement and improvement. All-Hazards Care A standardized, integrated, Cost-Benefi t Analysis Procedures implemented coordinated, and trained response for the provision of for classifying, recording, and allocating current care during all types of incidents. or predicted costs that relate to a certain product, production process, or outcome; in the context of Assessment Th e regular systematic collection, trauma systems, all known costs associated with the assembly, analysis, and dissemination of information system and actual care of injured people compared with on the health of the community. Th ese data, from a actual recovery and the good derived for individuals variety of sources, will assist in determining the status and the community. and cause of a problem and will identify potential opportunities for interventions. Data Collection Standards Clearly defi ned expectations and rules regulating the collection of Assurance Services necessary to achieve agreed- data. In the context of trauma systems, such standards on goals by encouraging actions of others (public or would include patient exclusion and inclusion criteria, private), requiring action through rules and regulations, common elements to be collected, and clear defi nitions or providing services directly. for each element collected to ensure consistency in data Authorization Legal power or right; sanction. collection and analysis. Available Resources Th e components required to Data Source A collection of information from which respond to injured patients and provide injury care (for one may make conclusions or inferences. In the context example, workforce, equipment, medications, supplies, of trauma systems, data sources aid in describing and facilities). the epidemiology of injury, care and outcome data, and cost of system and care and provide a tool for Benchmarks Global overarching goals, expectations, quality measurement in the system jurisdiction or outcomes. In the context of the trauma system, a using population-based data, clinical databases, and benchmark identifi es a broad system attribute. accounting data. Such sources may include vital Casualty Any person who is declared dead, missing, statistics and these types of data: EMS, ED, trauma injured, or ill as a result of an incident. center and hospital discharge, state police, medical examiner, trauma registry, rehabilitation, and mental Communications System An infrastructure that health and social services. facilitates fi eld-to-facility bidirectional connectivity, interfacility dialogue, and disaster service Dedesignation Th e revocation of trauma center communications among all parties. designation for noncompliance with preestablished criteria and standards for verifi cation and designation. Compliance Th e process of performing acts according to what is expected or required; in the Defi nitive Care Actions taken or implemented to context of trauma systems, for example, meeting ensure the needs of the patient are met. expectations required by the state to achieve trauma Designation (facility) Th e identifi cation of center status. capabilities or status based on predetermined criteria; Comprehensive Trauma System A coordinated in the context of trauma systems, the identifi cation inclusive system of care for injured people that of trauma centers based on the meeting of specifi c encompasses all phases of care, from the prehospital predetermined criteria.

Glossary of Terms, Acronyms, and Abbreviations 43 Determinant (of injury) A factor causing or First Responder In the context of trauma systems, contributing to the occurrence of trauma. personnel who arrive at the scene in early stages to provide the medical care necessary for injured people. Deterministic Data Linkage Data that are linked with patient identifi ers such as name and date of birth. Frontier Th e wilderness of woods, hills, mountains, plains, islands, and desert outside of urban and Disaster (major) As defi ned by the Staff ord Act, any suburban centers; all communities with a population natural catastrophe (including any hurricane, tornado, density of 20 or fewer persons per square mile and storm, high water, wind-driven water, tidal wave, located more than 60 miles or 60 minutes, or both, tsunami, earthquake, volcanic eruption, landslide, from the nearest market center. mudslide, snowstorm, or drought) or, regardless of cause, any fi re, fl ood, or explosion, in any part of Gap Analysis Th e analysis of the diff erence between the United States, which in the determination of trauma system standards and the compliance of the the president causes damage of suffi cient severity trauma system with those standards that result in the and magnitude to warrant major disaster assistance identifi cation of system needs. under this Act to supplement the eff orts and available Health Surveillance Inspection and assessment of resources of states, local governments, and disaster relief the physical and mental well-being of individuals living organizations in alleviating the damage, loss, hardship, in a defi ned location, that is, city, district, and others. or suff ering caused thereby. Incidence Th e degree or range of occurrence or Dispatch Th e central location for incoming eff ect. emergency calls requesting medical assistance. Based on information received, the coordination level of Incident An occurrence or event that requires prehospital providers and a Basic Life Support (BLS) an emergency response to protect life or property. or an Advanced Life Support (ALS) ambulance is Incidents may include major disasters, emergencies, determined, and a response team is directed to respond terrorist attacks, wild land and urban fi res, fl oods, to the emergency. hazardous material spills, nuclear accidents, aircraft accidents, earthquakes, hurricanes, tornadoes, tropical Emergency In the context of trauma systems, storms, war-related disasters, public health and medical the occurrence of critical or life-threatening injury emergencies, and other occurrences requiring an requiring triage and transportation to resuscitation emergency response. resources found in defi ned trauma centers. Incident Command System (ICS) A standardized Emergency Management Overseeing the on-scene incident management construct specifi cally multiagency coordination for mass casualty incident designed to provide for the adoption of an integrated preparedness, communication, mitigation, response, or organizational structure that refl ects the complexity recovery at a local, state, regional or national level. and demands of single or multiple incidents, without Emergency Preparedness Plan Th e specifi c being hindered by jurisdictional boundaries. ICS is measures, collaborative relationships, training, and the combination of facilities, equipment, personnel, capabilities that jurisdictions and agencies should procedures, and communications operating with a develop and incorporate into an overall system common organizational structure, designed to aid in to enhance operational readiness for incident the management of resources during incidents. management. Incident Management Refers to the totality of Epidemiology Th e science that investigates the activities to be aware of, prevent, prepare for, respond causes and control of epidemic diseases. to, and recover from incidents. Th e term is emphasized in the National Response Plan and replaces the terms Essential Services and Core Functions of Public emergency management, disaster management, crisis Health Th e central responsibilities of public management, and consequence management. health that contribute to and ensure the health of communities. Inclusive Trauma System A system that includes all health care facilities to the extent that their resources Facility Standards Rules established as a basis of and capabilities allow and in which the patient’s needs comparison for measuring or judging capacity, quantity, are matched to hospital resources and capabilities. See content, extent, value, and quality of services provided; Trauma System. in the context of trauma systems, rules defi ning resource availability and determining trauma and burn Indicator Th e tasks or outputs that characterize a care capabilities of hospitals. benchmark. Indicators identify actions or capacities

44 Regional Trauma Systems: Optimal Elements, Integration, and Assessment within the benchmark. Indicators are the measurable Performance Improvement (PI) Method for components of a benchmark. evaluating and improving processes that uses a multidisciplinary approach and that focuses on data, Infrastructure In the context of trauma systems, the benchmarks, and components of the system being identifi ed lead agency within the state; state trauma evaluated. manager; trauma advisory committee; and supporting legislative language, that is, rules and regulations; Policy Development A core function that uses trauma data system; identifi ed resource care facilities the results of assessments and scientifi c knowledge, (for example, levels of trauma centers and burn in an organized manner, to establish comprehensive centers); workforce; and other essential components policies intended to improve public health; a process of to facilitate the implementation, monitoring, and decision making that includes building constituencies, performance improvement of care provided to severely identifying needs and setting priorities, exercising injured people. legislative authority and providing funding to develop plans and policies to address needs, and ensuring the Injury Physical harm or damage to the body resulting public’s health and safety. from the transfer of or exposure to mechanical, thermal, electrical, or chemical energy or from the Population-based Data Analysis of data based on absence of such essentials as heat or oxygen. a given population. Th e US Census Bureau collects and publishes data on populations in the United States Injury Risk Assessment Th e process used to according to several defi nitions. Various systems then determine the likelihood that injury will result from an use the appropriate population to calculate rates. incident, taking into account the identifi cation of the hazard type, population aff ected, severity of injury, and Preparedness Th e range of deliberate, critical tasks volume or number aff ected. and activities necessary to build, sustain, and improve the operational capability to prevent, protect against, Interfacility Transfer Movement of a patient from respond to, and recover from domestic incidents. one care facility to another. In the context of trauma Preparedness is a continuous process involving eff orts at systems, interfacility transfer usually occurs in an eff ort all levels of government and between government and to move an injured patient to a higher level of care private-sector and nongovernmental organizations to where necessary resources optimize recovery. identify threats, determine vulnerabilities, and identify Jurisdiction A range or sphere of authority. Public required resources. Th e term “preparedness” is used agencies have jurisdiction at an incident related to their interchangeably with “readiness.” legal responsibilities and authorities. Jurisdictional Probabilistic Data Linkage A method of linking authority at an incident can be political, geographic data between 2 or more sources using a computerized (that is, city, county, tribal, state, or federal boundary judgment process. Linkage occurs through less certain lines), or functional (for example, law enforcement or identifi ers such as date of incident, patient age, sex, and public health). others. Lead Agency Th e agency responsible for trauma- Protocol Detailed plans for the triage, transport, EMS systems planning and program coordination resuscitation, and eventual defi nitive care of trauma within the state. patients. Protocols provide guidance for the care of Legislative Authority Statute and regulations. A trauma patients. statutory provision establishing and continuing a Public Health What we as a society do collectively government agency, activity, or program for a fi xed or to ensure the conditions in which people can be indefi nite period. healthy; a societal eff ort that addresses the health of the Mass Casualty Incident (MCI) A situation in which population as a whole rather than medical health care, a large quantity or number of physical injuries or which focuses on treatment of the individual ailment. deaths, or both, occur. Public health programs address the physical, mental, and environmental health concerns of communities Medical Oversight Th e responsibility of supervising and populations at risk for disease and injury. something (formal) relating to, involving, or used in medicine or treatment. Public Health Approach A proven, systematic method for identifying and solving problems. Improvements in Morbidity Th e relative incidence of disease; the the public health system, in partnership with the health condition of being diseased; the ratio of sick to well care system, can be accomplished through informed, persons in a community. strategic, and deliberate eff orts to positively aff ect health.

Glossary of Terms, Acronyms, and Abbreviations 45 Public Health Surveillance To watch or monitor population, such as pediatric, burn injury, or spinal public occurrences of disease or injury or both. cord injury patients. Public Health System A system to ensure a safe and Stakeholder A person or group of individuals with healthy environment for all citizens in their homes, direct interest, involvement, or investment in a matter; schools, workplaces, and such public spaces as medical in the context of trauma, an individual with interest care facilities, transportation systems, commercial in trauma care or trauma system development (for locations, and recreational sites. example, trauma surgeon, epidemiologist, EMS, ED director, or hospital administrator). Regional In the context of trauma system development, this term refers to intrastate-designated Surge Capacity Th e accommodation of the health trauma areas (regions). system to a transient sudden rise in demand for health care after an incident with real or perceived adverse Rehabilitation Services that seek to return a trauma health eff ects. patient to the fullest physical, psychological, social, vocational, and cognitive levels of functioning of which System Th e scheme of ideas, components, or principles he or she is capable, consistent with physiologic or by which something is organized; in the context of anatomic impairments and environmental limitations. trauma systems, designation, for example, of trauma centers, state trauma system plans, triage protocols, and Resource Standards Components of the trauma aeromedical and other transport procedures. system defi ned and identifi ed by the state as being essential state trauma system operations (for example, Trauma (traumatic injury) Tissue or organ injury, or ALS EMS, trauma centers, data repository, and others). both, sustained by the transfer of environmental energy. Response Activities that address the short-term, Trauma Center A specialized hospital or facility direct eff ects of an incident. Response includes with the immediate availability of specially trained immediate actions to save lives, protect property, health care personnel who provide emergency care on and meet basic human needs. Response also includes a 24-hour–7-day/week basis for injured people. Th ese the execution of emergency operation plans and of specially trained personnel are immediately available incident mitigation activities designed to limit the loss to treat patients with ready operating rooms, special of life, personal injury, property damage, and other equipment, and necessary supplies. Th e American unfavorable outcomes. College of Surgeons defi nes certain standards for each of the 4 levels of trauma centers that it identifi es. Risk Assessments Risk priorities determined by collecting and evaluating data and comparing the level Trauma System Plan A document in which the lead of risk against predetermined standards, target risk agency’s guiding members envision the future, identify levels, or other criteria (that is, injury risk assessments). system needs, and develop necessary procedures and operations to achieve that expectation. Th e plan will Regulation A rule or an order having force of law provide direction and function as a communication issued by the executive authority of the government. tool so that all within the system are functioning with Th e term “regulation” is often used interchangeably the same mind-set; following the same guidelines, with “rule.” policies, and protocols; and striving for the same goals Rule A principle or regulation set up by an authority, and objectives. prescribing or directing action or forbearance. Th e term Trauma System An organized, inclusive approach “rule” is often used interchangeably with “regulation.” to facilitating and coordinating a multidisciplinary Scoring Provides an assessment of the current system response to severely injured patients. A trauma status and marks progress over time to reach a certain system encompasses a continuum of care provision and milestone. Scoring breaks down an indicator into is inclusive of injury prevention and control, public completion steps. health, EMS fi eld intervention, ED care, surgical interventions, intensive and general surgical in-hospital Special Population Children, elderly, burns, ethnic care, and rehabilitative services, along with the social groups, disabled, and other populations who have chronic services and the support groups that assist injured physical, developmental, behavioral, or emotional health people and their signifi cant others with their return to conditions; populations living in rural or frontier areas. society at the most productive level possible. Specialty Care Facility An acute care facility that Trauma System Manager Th e individual within the provides specialized services and specially trained lead agency for trauma care who is responsible for the personnel to care for a specifi c portion of the injured

46 Regional Trauma Systems: Optimal Elements, Integration, and Assessment management, coordination, facilitation, and evaluation CV Curriculum vita of the trauma system. DALY Disability-adjusted life years Trauma System Standards Th e measures by which ED Emergency department a trauma system can be determined or evaluated (for example, facility standards, transfer protocols, triage EMS Emergency medical services protocols, and data collection standards). EMSC Emergency medical services for children Triage Sorting and determining priority; in the EMT Emergency medical technician context of trauma systems, a process for sorting patients by types and severity of injury to determine transport HRSA Health Resources and Services Administration to facilities where appropriate resources will exist to IC Incident command ensure optimal outcome. ICS Incident command system Triage Protocols Established, written plans for sorting and setting priorities; in the context of this ICU Intensive care unit document, having written plans, often backed by rules IOM Institute of Medicine and regulations that use severity of injury as a criterion for the determination of patient movement and transfer ISS Injury Severity Score to appropriate facilities. MADD Mothers Against Drunk Driving Verifi cation A process by which trauma care MCI Mass casualty incident capability and performance of an institution are evaluated by experienced on-site reviewers. MIS Management information system MOU Memorandum of understanding MTSPE Model Trauma System Planning and List of Acronyms Evaluation (2006) and Abbreviations NEMSIS National EMS Information System ABA American Burn Association NHTSA National Highway Traffi c Safety ACS American College of Surgeons Administration ACS-COT American College of Surgeons Committee NTDB National Trauma Data Bank on Trauma PI Performance improvement ALS Advanced Life Support PRQ Prereview Questionnaire ATCN Advanced Trauma Care for Nurses QA Quality assurance ATLS Advanced Trauma Life Support QALY Quality-adjusted life years ATS American Trauma Society SADD Students Against Destructive Decisions BIS Benchmarks, indicators, and scoring SCI Spinal cord injury BLS Basic Life Support STIPDA State and Territorial Injury Prevention CAAS Commission on Accreditation of Ambulance Directors Association Services TBI Traumatic brain injury CAHEA Council on Allied Health Education Accreditation TNCC Trauma Nursing Core Course CARF Commission on Accreditation of YPLL Years of productive life lost Rehabilitation Facilities

Glossary of Terms, Acronyms, and Abbreviations 47

APPENDIX B P Q (PRQ)

Section 1: Assessment Section 2: Policy Development Injury Epidemiology Statutory Authority and Administrative Rules 1. Describe the epidemiology of injury in your region 1. Describe how the current statutes and regulations and unique features of: allow the state or region to: a. Children a. develop, plan, and implement the trauma system, b. Adolescents b. monitor and enforce rules, c. Elders c. designate the lead agency, d. Other special populations d. collect and protect confi dential data, and 2. Describe the databases that are used to formulate e. protect confi dentiality of the quality the injury epidemiology profi le (for example, improvement process. population-based and clinical). 2. Describe the process by which trauma system 3. Have system epidemiology profi le results (for policies and procedures are developed or updated example, mortality rates, distribution of mechanism, to manage the system including: or intent) been compared with benchmark values? a. the adoption of standards of care, If so, please provide comparisons and origins of the benchmarks. b. designation or verifi cation of trauma centers, 4. Describe how emerging injury control patterns c. direct patient fl ow on the basis of designation, (for example, from trend or surveillance data) were d. data collection, and identifi ed and acted on. e. system evaluation. 5. Describe how ongoing and routine injury surveillance is completed and how results are 3. Within the context of statutes and regulations, shared with constituent groups. describe how injury prevention, EMS, public health, the needs of special populations, and Indicators As a Tool for System Assessment emergency management are integrated or 1. Has a multidisciplinary stakeholder group coordinated within the trauma system. participated in the scoring and consensus process associated with the BIS tool? If not, are there plans System Leadership to do so? 1. How does the lead agency bring constituency groups together to review and monitor the trauma 2. If the process has been completed, how were the system throughout each phase of care? fi ndings used? 2. Describe the composition, responsibilities, 3. Is there a date (year/month) set for a reassessment and activities of the multidisciplinary trauma using the BIS to mark progress toward agreed-on system advisory committee(s) and the working goals or benchmarks? relationship(s) with the trauma lead agency and the EMS lead agency, if they are diff erent.

Prereview Questionnaire (PRQ) 49 a. Identify pediatric representatives on the Lead Agency and Human Resources multidisciplinary trauma system advisory Within the Lead Agency committee and any pediatric advisory groups 1. Describe the number, position titles, and that provide input into trauma system percentage of full-time equivalency of all personnel development. within the lead agency or contract personnel b. Describe the process of involving experts in, who have roles or responsibilities to the trauma and advocates for, special populations and how program. they help drive regional trauma system policy. 2. Identify other personnel resources that support c. Describe how the multidisciplinary advisory the trauma program activities of the lead agency committee is involved in trauma system (for example, epidemiology support from other performance evaluation (for example, review units within the health department, public health of system performance reports). interns) 3. Provide examples of how the lead agency and 3. Describe the adequacy of personnel resources trauma system leadership (for example, trauma available to the lead agency to sustain trauma centers, trauma medical director, nurse program assessment, policy development, and coordinator, trauma administrator, and other assurance activities. stakeholders) inform and educate policy makers, a. Identify impediments or barriers that hinder elected offi cials, community groups, and others system development. about the trauma system, its strengths, and its improvement opportunities. Trauma System Plan 4. Describe the process to build or expand eff ective 1. Describe the process for the development or trauma leadership within the trauma system (for revision of the trauma system plan. example, succession planning, leadership courses, a. Include the role of advisory and stakeholder workshops), including the lead agency and trauma groups in the process. centers. 2. Is there ongoing assessment of trauma resources Coalition Building and Community Support and asset allocation within the system? 1. What is the status of the trauma system’s coalition 3. Describe the process used to determine trauma (for example, What is the status of recruiting system standards and trauma system policies. members and building a coalition? Is the coalition strong and active coalition? Does the coalition a. How are they reviewed and evaluated? need new energy? Who is not currently involved b. What standards and policies exist for special but should be a part of your coalition?)? populations, including rural and frontier a. What is the role of the coalition members regions? (constituents and stakeholders) in promoting c. How are specialized needs addressed, including trauma system development? burns, spinal cord injury, traumatic brain b. What is the method and frequency for injury, and reimplantation? communicating with coalition members? System Integration 2. Describe how the trauma system leadership 1. What is the trauma system’s collaboration mobilizes community partners to improve the and integration with EMS, public health, and trauma system through eff ective communication emergency management and programs such as: and collaboration. a. prevention programs, a. How has the community been approached to identify injury control concerns? b. mental health, b. What key problems has the community c. social services, identifi ed? d. law enforcement, c. How do stakeholders bring system challenges e. child protective services, and or defi ciencies to the attention of the lead agency? f. public safety (for example, fi re, lifeguard, mountain rescue, and ski patrol)?

50 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Financing Emergency Medical Services 1. How does the lead agency track and analyze 1. Provide information on the last assessment of internal trauma system fi nances? EMS, including assessor and date. a. How does the advisory committee participate a. Describe the EMS system, including the in the fi nancial review process? number and competencies (that is, ALS or BLS) of ground transporting agencies, b. How frequently are trauma system fi nancial nontransporting agencies, and aeromedical reports published? resources. c. Which fi nancial data are reported (lead agency b. How are these resources allocated throughout data, health facility data, or both)? the region to service the population? 2. What is the lead agency’s budget for the trauma c. Describe the availability of enhanced 911 and system? wireless E-911access in your region. 3. What is the source of funding available to support d. Identify any specialty pediatric transporting the development, operations, and management agencies and aeromedical resources. of the trauma system (for example, general funds, dedicated funds)? e. Describe the availability of pediatric equipment on all ground transporting units. 4. What fi nancial incentives and disincentives exist to encourage trauma center participation in the 2. Describe the procedures for online and off -line trauma system? medical direction, including procedures for the pediatric population. a. Specifi cally include arrangements for uncompensated and undercompensated care. a. Describe how EMS and trauma medical direction and oversight are coordinated and integrated. Section 3: Assurance 3. Describe the prehospital workforce competencies in trauma: Prevention and Outreach a. Initial training and certifi cation/licensure 1. List organizations dedicated to injury prevention requirements within the region and the issues they address (for example, MADD, SADD, SafeKids Worldwide, b. Continuing education and recertifi cation/ Injury Free Coalition for Kids, American Trauma relicensure requirements Society, university-based injury control programs). c. Pediatric trauma training requirements for 2. Describe how the trauma lead agency has funded recertifi cation and coordinated system-wide injury prevention or Defi nitive Care Facilities outreach activities. 1. Describe the extent to which all acute care facilities a. Which injuries (including pediatric injuries) participate in the trauma system. have been identifi ed and prioritized for intervention strategies? a. Describe the availability and roles of specialty centers within the system (pediatric, burn, b. Identify any dedicated lead agency or other traumatic brain injury, spinal cord injury) agency staff member (full- or part-time) responsible for injury prevention outreach and 2. Describe the roles of the nondesignated acute care coordination for the trauma system. facilities in the trauma system. c. What is the source of funding? a. Address their representation on the regional trauma committee. 3. Explain the evaluation process for injury prevention projects that are conducted by the lead b. Do they submit registry and/or fi nancial data? agency, trauma facilities, or other community- c. What is their degree of engagement in the based organizations. system-wide performance improvement process? a. Identify any gaps in injury prevention eff orts 3. Describe the process for verifi cation and for population groups in the state. designation. Briefl y outline the extent of authority

Prereview Questionnaire (PRQ) 51 granted to the lead agency to receive applications injury are triaged from the fi eld to appropriate and to verify, designate, and dedesignate regional facilities. trauma centers. 2. Within the system, what criteria are used to guide 4. Describe your standards for trauma center the decision to transfer patients to an appropriate verifi cation (including pediatric standards) and resource facility and are these criteria uniform the extent to which they are aligned with national across all centers? standards. 3. Specify whether there are interfacility transfer a. Describe any waivers or program fl exibility agreements to address the needs of each of the granted for centers not meeting verifi cation following: requirements. a. Transfer to an appropriate resource facility b. Describe the process and frequency of use for b. Traumatic brain injury dedesignation of trauma centers. c. Spinal cord injury 5. Outline how the geographic distribution and number of designated acute care facilities is aligned d. Reimplantation with patient care needs. e. Burns a. Describe the process by which additional f. Children trauma centers are brought into the system. g. Repatriation b. Describe the system response to the voluntary withdrawal of designation by acute care facilities. 4. Describe the system-wide policies addressing the mode of transport and the type and qualifi cations c. Describe the mechanism for tracking and of transport personnel used for interfacility monitoring patient volume and fl ow between transfers. centers and how this infl uences the overall confi guration of designated facilities. 5. Specify whether there is a central communications system to coordinate interfacility transfers. 6. Describe your system for assessing the adequacy Describe how this system has access to information of the workforce resources available within regarding resource availability within the region. participating centers. a. Address nursing and subspecialty needs (trauma Rehabilitation or general surgery, intensivists, neurosurgeons, 1. Provide data about the number of rehabilitation orthopedic surgeons, anesthetists, pediatric beds and specialty rehabilitation services (spinal surgeons, and others, as required). cord injury, traumatic brain injury, and pediatric) available within the trauma system’s geographic b. What human resource defi ciencies have been region. On average, how long do patients need to identifi ed and what corrective actions have wait for these rehabilitation beds? Does the average been taken? wait vary by type of rehabilitation needed? 7. Describe the educational standards and 2. Describe how existing trauma system policies credentialing for emergency physicians and and procedures appropriately address treatment nursing staff , general surgeons, specialty surgeons, guidelines for rehabilitation in acute and and critical care nurses caring for trauma patients rehabilitation facilities. in designated facilities. 3. Identify the minimum requirements and a. What regional educational multidisciplinary qualifi cations that rehabilitation centers have conferences are provided to care providers? established for the physician leaders (for example, Who is responsible for organizing these events? medical director of spinal cord injury program, System Coordination and Patient Flow medical director of traumatic brain injury program, and medical director of rehabilitation 1. Describe the source of prehospital trauma triage program). protocols, and specify whether they are consistent with national guidelines. 4. Describe how rehabilitation specialists are integrated into trauma system planning and a. Describe how children and patients with advisory groups. severe traumatic brain injury and spinal cord

52 Regional Trauma Systems: Optimal Elements, Integration, and Assessment Disaster Preparedness defi nitive care. If yes, specify the mean time to 1. When was the last assessment of trauma system transfer. preparedness resources conducted, and what were b. Proportion of patients with injury more severe the signifi cant fi ndings of the assessment as they than a predefi ned injury severity threshold (for relate to emergency preparedness? example, ISS >15, or other criteria) who receive 2. What actions were taken to remediate or mitigate defi nitive care at a facility other than a Level I the gaps identifi ed through tabletop or simulated or II trauma center (undertriage) responses in disaster drills among the acute care c. Proportion of patients with injury less severe facilities participating in the system? than a predefi ned injury severity threshold (for 3. What is the trauma system plan to accommodate example, ISS <9) who are transferred from a need for a surge in personnel, equipment, and any facility to a Level I or II trauma center supplies? (overtriage). 4. How is the trauma system integrated into 5. Describe how your system addresses problems the state’s incident command system and the related to signifi cant overtriage or undertriage, communications center? both primary and secondary. 5. What strategies and mechanisms are in place to Trauma Management Information Systems ensure adequate interhospital communication 1. Which agency has oversight of the trauma during a mass casualty incident? management information system? System-wide Evaluation a. Describe the role and responsibilities of this and Quality Assurance agency in collecting and maintaining the data. 1. What is the membership of the committee charged b. How are the completeness, timeliness, and with ongoing monitoring and evaluating of the quality of the data monitored? trauma system? 2. Specify which of the following data sources are a. To whom does it report its fi ndings? linked to the information system. Describe the b. How does it decide what parameters to method of linkage (for example, probabilistic or monitor? deterministic). c. What action is it empowered to take to a. Motor-vehicle crash or incident data improve trauma care? b. Law enforcement records 2. Describe the trauma system performance c. EMS or other transporting agency records improvement eff orts as they pertain to the system for the following groups of providers in the context d. Emergency department records of system integration: e. Hospital records (hospital trauma registries) a. Dispatch centers f. Hospital administrative discharge data b. Prehospital provider agencies g. Rehabilitation data c. Trauma centers h. Coroner and medical examiner records d. Other acute care and specialty facilities i. Financial or payer data e. Rehabilitation centers j. Dispatch 3. List the process and patient outcome measures that 3. What are the regional trauma registry inclusion are tracked at the trauma system level, including criteria? measures for special populations. 4. Which stakeholders had a role in selecting the data 4. As part of your system-wide performance elements for inclusion into the regional registry? improvement, specify whether each of the following is assessed on a regular basis: a. From what source(s) were the data fi eld defi nitions derived? a. Time from arrival to a center and ultimate discharge to a facility capable of providing b. What pediatric data elements are captured?

Prereview Questionnaire (PRQ) 53 5. What local or system-wide reports are routinely 3. Provide examples of where research was conducted generated and at what frequency? for the purpose of providing evidence that the processes of care and outcome of injured patients 6. Are data contributed to the National Trauma Data in the system’s region are within acceptable Bank (NTDB) or other outside agencies? If so, standards. please specify which agencies. 4. How has research been used to modify policy or Research practice within the system? 1. Describe the current procedures and processes investigators must follow to request access to the 5. What resources (for example, personnel and trauma system registry. fi scal) are available to the lead agency to assist in conducting system research? 2. What are the mechanisms used to ensure patient confi dentiality when regional trauma registry data are used by investigators?

54 Regional Trauma Systems: Optimal Elements, Integration, and Assessment