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Trauma Systems

Trauma Systems. John P Hunt MD MPH Professor of Surgery LSU – New Orleans. Goals & Objectives. Understand what influences the organized response in caring for injury Appreciate the magnitude of trauma as a Public Health problem Understand the different components of a trauma system

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Trauma Systems

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  1. Trauma Systems John P Hunt MD MPH Professor of Surgery LSU – New Orleans

  2. Goals & Objectives • Understand what influences the organized response in caring for injury • Appreciate the magnitude of trauma as a Public Health problem • Understand the different components of a trauma system • Be aware of the changing demography of the physician & surgical workforce • Grasp the impact of Trauma Centers and Systems on quality of Care

  3. Goals & Objectives • Understand the costs incurred with them • Appreciate impediments to trauma system development • Understand important legislation affecting the organized response to trauma • Review the existing infrastructure • Discuss potential solutions, changing landscape, and future

  4. What is a Trauma System? Who runs it?? “Trauma is a surgical disease from start to finish” Norman McSwain

  5. What is a Trauma System? https://www.facs.org/quality-programs/trauma/tsep/components

  6. Trauma system criteria • Authority to designate • Existence of a designation process • ACS standards for trauma centers • On-site verification, out-of-state surveyors • Authority to limit trauma centers • Pre-hospital triage protocols • Trauma center performance monitoring • Statewide coverage of system

  7. Trauma Systems, Easy?

  8. Pressures & Forces

  9. The ProblemNationwide • 4th leading cause of death in the country • Accounts for 6% of all deaths • Leading cause of death in people under 45 years of age • Responsible formore years of productive life lost than any other disease Fingerhut L, Warner M. Injury Chartbook. Health, United States 1996-1997.

  10. Disease Comparisons Deaths/Year Cause CDC.GOV 2001

  11. Years of Life Lost Years potential life lost Cause CDC.GOV 2001

  12. The Problem-Louisiana Louisiana-78.39

  13. Pressures & Forces

  14. Physician Shortage • 20 year moratorium on new medical schools • No increase in class size • Population • 1980 - 248 million • 2010 - 308 million • By 2020, there will be a 20% deficit of physicians Cooper R. Ann Int Med. 2004;141:705.

  15. Surgical Workforce • 1980-1990’s emphasis on Primary Care • Stable number of General Surgery residents graduating each year (1,000/year) • 1981 – 17,394 General Surgeons 2010 – 17,727 General Surgeons • Increasing specialization • Changes in Surgeon attitudes Terhune KP et al. J Amer Coll Surg. 2010;210:990.

  16. Surgical Workforce • Physician Workforce Enhancement Act of 2009 • Loans to hospitals starting residency programs • Resident Physician Shortage Reduction Act of 2009 • 15% (15,000) increase in residency positions funded Physician Workforce Enhancement Act of 2009 in HR 914 Resident Physician Shortage Reduction Act of 2009 in HR 2251 Resident Physician Shortage Reduction Act of 2009 in S.973

  17. Sub-specialization Stritzenberg KB et al. J Am Coll Surg 2005;201:925

  18. Fellowships Results and data: Specialties matching service. 2010 appointment year,NRMP Results and data: Specialties matching service. 2015 appointment year,NRMP

  19. Surgeon Attitudes • 70% of General Surgery residents found Trauma Surgery unappealing • 60% of those stated life-style as the primary issue Reed CE, et al. J Am Coll Surg. 2009;210(3):319 Hadzikadic et al. Arch Surg 2010;145(5):445

  20. Trauma Surgeon Workforce • 1.7 positions currently unfilled at Level I & II Trauma Centers • 1.2 FTE’s expected to retire within 3 years • Shortage of 1,500 Trauma specialists by 2012 • Louisiana could use at least 20 – 25 more trauma surgeons Cohn SM, et al. J Am Coll Surg. 2009;209(4):446.

  21. Pressures & Forces

  22. Trauma Centers • 18 Level I, 51 Non-trauma center • 4,087 survivors and 1,104 deaths MacKenzie EJ et al. NEJM 2006;354:366

  23. Orange County Experience • 73 % of deaths were deemed clearly or potentially preventable* • After institution of trauma system- preventable death rate droped from 34 to 15%** Preventable death *West JG et al. Arch Surg 1979;114:455 **Cales RH et al. Ann Em Med 1984;13:15

  24. San Diego Experience • Preventable deaths dropped from 13.6% to 2.7% • Sub-optimal care dropped from 32% to 4.2%* *Shackford SR et al J Trauma 1986;26:812

  25. Trauma Systems • Single state, 10 – year period • 1 verified Trauma Center to 4 verified centers • 40,063 patients ISS % Mortality Year Tinkoff GH, et al. J Trauma. 2010;69:245.

  26. Pressures & Forces

  27. Cost • 5,043 major trauma patients • 69 hospitals in 14 states • 18 Trauma Centers, 51 Non-trauma Centers • $36,319 per Life-year gained • $36,961 per QALY gained • $790,931 per Life gained MacKenzie EJ, et al. J Trauma. 2010;69:1.

  28. Trauma Center Attrition • From 1983 to 1990, 66 Trauma Centers, in 14 different states, closed • Reasons cited – Uncompensated, high operating costs, Physicians unwilling, ▲ in designation requirements* *Dailey JT et al J Trauma 1992;33:539

  29. Problem “It was wonderful. Big committees met, everything was fine. And the first thing that happened was some poor sonofabitch got run over and didn’t have a penny, and he ends up at one these for-profit hospitals. They found out very quickly this was going to be a loser” B. Boyd Benjamin Chairman, Dade County Public Health Trust 2/25/90

  30. Pressures & Forces

  31. EMTALA • If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either • within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or • for transfer of the individual to another medical facility in accordance with subsection (c) of this section. United States Code Title 42, 1395dd

  32. Pressures & Forces

  33. Louisiana Emergency Response Network (LERN) • 2004 - Created by state legislature (LA RS 40:2841‐2846) • Nine regional commissions • Concept - Communications Center • 2007 – Legislation providing liability limitations • 2009 - Trauma System Evaluation and Planning Committee (TSEPC) • 2010 – State Trauma Registry

  34. Louisiana Emergency Response Network (LERN) • 2014 – 113 of 116 (97.4%) hospitals with ED services participate in LERN • 2014 – 30 of 54 (55.6%) of EMS services in state use LERN • 2014 – Stroke and STEMI patients routed • 2014 - $1,522,871 budget • 2017 – ACSCOT TQIP collaborative

  35. LERNDestination Protocol LERN Annual Report 2013-2014

  36. LERN Communications Center 2011 - 11,743 2012 - 14,846 2013 - 14,492 2014 - 15,602* *2014 Volume Includes Stroke and STEMI LERN Annual Report 2013-2014

  37. Solution-Centers & Systems • 67.1%-Trauma Center < 60 miles • 67.6%-Trauma = Tertiary Care Center • 90.0%-Tertiary Care Center hire Surgeons • 71.8%-Transfer problems • 86.1%-Favor a state system Timmer J, et al. J La Med Soc. 2012;164:131

  38. Trauma Center Development • 85% of the US population lives 1 hour from a trauma center Branas, et al. JAMA. 2005;293:2626 Verified Trauma Centers-ACS COT Web site - 2015

  39. Hunt’s Louisiana Campaign2000

  40. Hunt’s Louisiana Campaign2005 Jacome 2005 Duchesne 2005

  41. Hunt’s Louisiana Campaign2010 Timmer 2009 Jacome 2005 Cayton 2006 Wright 2008 Duchesne 2005 Fahr 2010 Stuke 2009

  42. Hunt’s Louisiana Campaign2015 Whitlock 2011 Timmer 2009 Duke 2014 Zeringue 2015 Duchesne 2013 Robledo 2015 Hidalgo 2014 Jacome 2005 Cayton 2006 Stuke 2009 Fahr 2010 Greiffenstein 2012 Gruner 2013 Rau 2013 Schroll 2013 Moore 2015

  43. LERN Communications Center Martinez B, Et al. J Amer Coll Surg 2017;225(4):508-15

  44. Transfer Rate Comparison 312/1,034 (30.2%) 570/13,037 (4.3%) p < 0.01 Martinez B, Et al. Accepted for publication J Amer Coll Surg

  45. Mortality Comparison 21/1,034 (2.03%) 82/13,037 (0.6%) p < 0.0001 Martinez B, Et al. J Amer Coll Surg 2017;225(4):508-15

  46. Trauma system criteria Authority to designate Existence of a designation process ACS standards for trauma centers On-site verification, out-of-state surveyors Authority to limit trauma centers Pre-hospital triage protocols Trauma center performance monitoring Statewide coverage of system

  47. LERN – Added BenefitsEducation • 32 TNCC courses – 290 nurses certified • 4 RTTDC courses with 73 participants • MCI course – 27 classes with 678 participants • 14 Disaster response drills • Trained 250 State troopers in hemorrhage control

  48. LERN – Added BenefitsMCI management • Primary coordinating center for MCIs • Supported 169ESF-8 calls and 296 alerts

  49. Questions

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