arizona trauma system consultation
DESCRIPTION
Arizona Trauma System Consultation. Arizona. Area – 113,998 sq mi (6 th ) Population – 6.5 million ( 16th ) Density 57/sq mi (33 rd ) Trivia 48 th State – 1912 The Grand Canyon State “ Ditat Deus” Saguaro Blossom Palo Verde State Drink ??. Current Status. Current Status. - PowerPoint PPT PresentationTRANSCRIPT
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ArizonaTrauma System
Consultation
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Arizona
• Area – 113,998 sq mi (6th)• Population – 6.5 million (16th)
• Density 57/sq mi (33rd)• Trivia
• 48th State – 1912• The Grand Canyon State• “Ditat Deus”• Saguaro Blossom• Palo Verde• State Drink ??
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Current Status
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Long history of trauma system development Seven historical high-level centers◦ Located in urban areas◦Align with majority of population
Initial Trauma System consultation – 2007 Substantial increase in trauma centers New challenges with center distribution Perceived lack of strong central leadership Stakeholder frustration Substantial focus on Phoenix metro area
Current Status
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Inclusive system by intent Still an exclusive system in operational reality Sufficient high-level trauma center resources◦7 level I and II adult centers◦1 level I pediatric center◦Some degree of maldistribution
Perception of oversupply in some areas Clear undersupply in some areas
Well developed EMS, highly collaborative No strong central control of trauma system◦Historical reliance on guidelines instead of rules
Current Status
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Substantial funding◦State budget◦ Proposition 202
Many areas of strength within BEMSTS◦Historical focus on EMS over trauma
Substantial progress since prior consultation Historical challenges remain New challenges have arisen
Current Status
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Progress since 2007
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Definitive Care Facilities All hospitals should be designated as trauma centers
or participating hospitals as part of a statewide inclusive trauma care system.
Substantial progress has been made with the addition of 18 new trauma centers, most in underserved areas
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Information Systems The Arizona state trauma registry should expand its
reach to include all acute care hospitals in the state.
Substantial progress. All designated trauma centers and an additional two non-designated facilities now contribute data
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Leadership Establish and fund a trauma medical director
position to work under the guidance of the Bureau Chief.
Trauma medical director currently funded at 0.25 FTE
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Research Develop a statewide trauma research consortium,
linked to the activities and functions of the STAB and AZTQ, for purposes of promoting research throughout the continuum of trauma care.
Partially implemented. NIH funded TBI study in progress, AZTrACC plan to coordinate multi-institutional research projects.
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Our priority:The best interest of the
patient
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Long history of strong participation◦ Institutions◦Trauma leadership◦ People
Substantial funding ADHS and BEMSTS leadership committed Sufficient number of high level centers Rapid increase in rural level IV trauma
centers Growth of capacity outside urban areas Fewer reported issues with diversion
Advantages and Assets
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Sophisticated and collaborative EMS Strong regulatory oversight of EMS Adoption of CDC triage guidelines Good trauma plan from 2005 Robust data infrastructure, including DQA Collaborative research infrastructure Diverse injury prevention programs Disaster preparation at level of facilities
Advantages and Assets
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Large remote land area, geographic isolation Limited resources in rural areas Potential maldistribution of trauma centers Lead agency lacks (or perceives itself to lack)
clear authority and mandate Limited clinical trauma expertise in lead
agency Historical reliance on guidelines vs rules Outdated advisory board structure Lack of cohesive stakeholder involvement Incomplete acceptance of inclusive system
Challenges andVulnerabilities
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Mechanics of distribution of Prop 202 funds creates adverse incentives
Inability to designate centers based on need Lack of clear destination protocols Limited system-level integration with
emergency preparedness efforts Immature processes for system monitoring Limited utilization of available data Lack of clear constituency and legislative
support
Challenges andVulnerabilities
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Themes There must be a clear vision and a clear plan for
future direction, embraced by all stakeholders and by the bureau
Bureau needs to have clear support from stakeholders to lead, backed up by statutory and regulatory authority
Advisory committee need to be reconfigured to provide broader stakeholder participation and establish clear acceptance as balanced policy development group
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Themes Trauma center designation should be based on
need Choice of destination from field or transfer should
be consistent, and driven only by patient needs Prop 202 funds not being used to their full
potential◦ No support for centers other than level 1◦ Distribution model fosters competition for volume
Sometimes you need rules Remember you are all on the same team The time to start is now
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Focus Questions
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1a. - What evidence-based changes to our trauma system can you make to improve the delivery, efficiency and cost-effectiveness of trauma care to our citizens? ◦Designate centers based on need and
performance◦Develop and enforce specific destination
standards◦Re-evaluate the way that Prop 202 funds are used
Changes to Arizona Statutes and Rules
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1b. - Do you see a need for specific changes in our statutes and rules? If yes, what are they? ◦Establish need as a pre-requisite for designation◦Establish destination protocols◦Determine a new distribution plan for Prop 202
funds
Changes to Arizona Statutes and Rules
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2. - What recommendations can you make regarding how our statutory committees and regions currently provide clinical direction and oversight in regards to trauma care in our State? ◦Restructure the advisory board to include all time-
sensitive illnesses◦Ensure balanced representation from entire state◦Establish destination standards in rule◦Enhance role of regional councils
Arizona Focus on Guideline vs Rule
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3. - What specific process and outcome metrics would you recommend to best measure the effectiveness of our state trauma system? ◦A good preliminary list was provided in the 2007
report, including metrics regarding over and under triage, time to transfer, necessity for or failure to transfer, and deaths in non-trauma centers.
ADHS Focus on Using Data to Enhance the System
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4. - What recommendations can you make to enhance the participation, evaluation and performance improvement of the rehabilitation community as a component of our system? ◦ Identify a funding source for rehab facilities◦Collect performance and outcome data from
rehab facilities◦Actively collaborate to solve patient flow issues
Rehabilitation Participation in the Trauma System
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Key Recommendations 2012
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Statutory Authority and Administrative Rules Amend trauma system statutes and rules to:◦Require a demonstration of need as a requirement for any
provisional trauma center designation ◦ Establish standards of care relative to specific trauma
destination protocols: Establish a state template in rule based on CDC field triage
criteria Provide authority to the regions and require them to use the
state template by rule to develop detailed destination procedures based on state template.
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System Leadership Encourage broader participation and more frequent
turnover of committee membership Regularly convene and empower a trauma program
manager group to be a system advocate, contribute to trauma system development, inform the BEMSTS, and support TEPI in performance improvement efforts.
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Lead Agency and Human Resources Within the Lead Agency Establish a separate trauma medical director
position (trauma surgeon) to provide the needed trauma system leadership and vision.
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Trauma System Plan Revise the Arizona trauma system plan in a broad
based ad hoc subcommittee of the multidisciplinary trauma advisory committee. ◦ Ensure balanced rural and urban participation. ◦Adopt the plan formally through a broad trauma
stakeholders group, trauma advisory committee, and ADHS.
Perform a statewide needs assessment to evaluate optimal center placement prior to granting any new requests for provisional trauma center designation.
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System Integration Improve integration efforts between system leadership
and Level III/IV trauma centers.◦ Include level III and IV representation on advisory committee
Optimize the integration of STAB and the EMS Council◦ Have more frequent meetings, and stagger the schedule to allow
members with dual appointments to attend all meetings. ◦ Leverage electronic resources to facilitate meeting
participation. ◦ Consider ad hoc workgroups to facilitate efforts.◦ Increase trauma representation on EMS council.
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Financing Revise distribution method for Prop 202 funds to
provide funding for all designated trauma centers in the system ◦ Change rule to ensure that all designated trauma centers
receive level appropriate support for the “cost of readiness” ◦Develop a formula for distribution of funds that focuses on
specific deliverables by level rather than volume and acuity◦ Include a mechanism to support trauma rehab services◦Revisit allocation method/ formula on a regular basis
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Financing Distribute funds through contractual agreement to
ensure that each center continuously meets all of the requirements of verification/designation
Regularly monitor and audit fund distribution Require hospitals to demonstrate that funds are
used to support trauma service readiness and level-specific system participation
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Definitive Care Facilities Impose a moratorium on additional trauma center
designation in Maricopa and Pima counties to allow for appropriate trauma system plan development.
Establish criteria and standards for designation and de-designation of trauma centers based upon need and performance.
Establish geographic catchment areas for individual high-level trauma centers to balance load, ensure effective outreach, minimize temporal maldistribution, and mitigate adverse effects of competition
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System Coordination and Patient Flow
Establish regional destination standards and monitor compliance. ◦Develop a state framework that can be adapted regionally. ◦ Clearly identify which facilities are appropriate to receive
patients identified in each step of the field triage criteria. Use BEMSTS’ statutory authority to mandate EMS
services comply with accepted field triage destination standards.
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Rehabilitation Identify funding sources to facilitate the timely
transfer of patients with uncompensated care to rehabilitation facilities.
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System-wide Evaluation and Quality Assurance Select the first audit filter from the provided list for
review as part of TEPI’s trauma system performance improvement activities ◦ Schedule a meeting, and then start the review process.
Encourage the trauma system program manager to contact the NASEMSO trauma managers council for sample state trauma system PI plans. ◦Use these resources to develop a state trauma system PI
plan in collaboration with TEPI
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Trauma Management Information Systems Identify and convene a work group to develop
reports assessing measurable objectives of trauma system performance◦ Include metrics such as distribution of patients, transfer
patterns, time to definitive care (field and transfer) Assign TEPI to develop of a list of standardized
reports to be run on a quarterly basis that will assist in ongoing monitoring of trauma system performance
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Trauma Management Information Systems Run and review the same list of reports for at least
one full year before adaptation, deletion or substitution
Distribute the reports widely to stakeholders and advisory bodies.
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Observations This is a consultative process◦The recommendations offered are based on broad
general principles and experiences in other regions
◦The solutions will be unique and specific to Arizona Change is always difficult Progress will require an ongoing
collaborative effort by all stakeholders The solutions will be created by all of you Audentes fortuna iuvat
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• Robert J. Winchell, MD, FACS Team Leader• Christopher C. Baker, MD, FACS Trauma Surgeon• Jane Ball, RN, DrPH ACS Consultant• Rajan Gupta, MD, FACS Trauma Surgeon• Heidi A. Hotz, RN Trauma Program
Manager• Janet Kastl, MA State EMS Director• Nels D. Sanddal, PhD, REMT-B ACS Staff• James D. Upchurch, MD Emergency Physician• Carol Williams ACS Staff
Closing Comments