the impact of l3 trauma centers in pa 10 25 12 dave
TRANSCRIPT
The Impact of Including
Level III Trauma Centers in
Pennsylvania16th Annual PTSF/PaCOT Conference
October 25, 2012
Juliet Geiger RN, MSN –Executive Director, PTSFDavid Scaff, DO – Trauma Program Medical
Director, Pocono Medical Center
Historical Background
• 1985 – Standards of Accreditation for Adult L1/2 and Pediatric L1 trauma centers developed
• 1992 – L2 Pediatric Standards developed
• 2004 – Act 15 0f 2004 signed mandating L3 standards be developed
• 2012 – One accredited L3 hospital, two hospitals pursuing L3 accreditation
Questionnaire
• Questionnaire sent to eligible hospitals that received pursuit funding and those eligible hospitals that elected not to pursue accreditation in order to describe:– Reasons for pursuing or not pursuing Level III
accreditation– Barriers preventing a hospital from pursuing
accreditation– Barriers to becoming accredited for those that
received funding– Resources that would have helped with pursuit– Factors that would be necessary before pursuing
accreditation in the future.– Outcomes as a result of pursuit effort
Results:Reasons for Pursuing
Accreditation
• Enhanced quality of care • Increased marketing of hospitals to
generate higher volumes of patients
• Receipt of grant funding
Results: Positive Outcomes
• Enhanced level of care of injured patients
• Improved care of all patients within hospital
• Implementing standardized protocols and policies for care of injured patients
• Energized nursing and physician staff in the care of injured patients
• Improved Performance Improvement efforts
Barriers to Pursuing Accreditation: Surgeon
SupportFeared increased patient volumes and
injury severity
County A (accredited 2009) County B (Accredited 2008)
Barriers to Pursuing Accreditation: Physician
Leadership
• Trauma Medical Director must be a surgeon
• Rural areas predominately have private practice physician groups
• Peer Review process challenging
Barriers to Pursuing Accreditation: Funding
• Administration feared insufficient funding and disappearance of funding.
• In 2010 a two year delay did occur due to the West Virginia lawsuit that delayed trauma funding to all trauma centers and those pursuing accreditation.
Barriers to Pursuing Accreditation: Education
• From PTSF– Education limited to state wide in-
person forums with limited 1:1 visits– L3 inclusion started almost 20 years
after L1/2 trauma centers developed
• From Trauma Centers – Unclear of role and how to support L3
development– Not fully supportive of L3 inclusion in PA.
PTSF Next Steps… • Foster relationship building between higher
level trauma centers and their rural colleagues• Enhance PTSF’s educational approach • Continue Level IV trauma center development• Perform trauma system research geared toward
measuring the trauma center/system value. • Continue to advocate for state and federal
funding of trauma centers• Embark on a public education campaign
• 2 Fellowship trained Trauma Surgeons– 7 at partner level I
• 4 General Surgeons– 1 at partner level I
• 3 Trauma Physician extenders
• Trauma Program Manager
• Trauma PI Coordinator
• Data Analyst/Registrar
• Registrar
• Administrative Support
The Trauma Service at PMC
Keys to Level III success
• P P -Personnel
• C C -Commitment
• P P -Partnership
Personnel
• Trauma Program Manager– Patient care experience – Organized– Resourceful– Relationship builder– Team philosophy– Conflict resolution
Personnel
• ER Medical Director– Committed to trauma development– Relinquish autonomy– Respected by colleagues– Gateway to EMS community
Personnel
• Trauma Medical Director – Identify the “Players”/understand the
culture– Listen : talking ratio 3:1– Inclusive to existing medical staff– Standards of care– Fair to all parties involved– Lead by example– Think outside the box– Be the “Champion”
Commitment
• Board & Administrative Commitment– Long term vision = Long term gains– Start up cost/loss of revenue– Recognize limitations of institution– Recognize trauma involvement is all
areas– Commitment to cultural change– Adequate staffing – MD’s / PA-C’s / NP’s– Ask for help/accept support
Partnership
• Long term commitment / contract• Guidance on trauma service
development• External PI review• Staffing resources• Guideline development• Trauma department resource
“Halo”• Massive Transfusion Protocol• Improved ER triage• Nursing education• Increased blood bank capacity• Development of Performance
Improvement Process• Preparation for the unexpected• Public/Patient Satisfaction• Pride in Institution
Halo Effect - 2009• 22 yo Female, Acute abdominal pain
– BP 85/66, HR 110– Rapid triage– Ultrasound confirmation of significant
abd fluid– Resus begun (Blood & crystalloids)
– To OR in 30mins – Ruptured Ectopic– Home Day 3
– “Thank you, 2 years ago the outcome might not have been the same”
– Kris Farrell, CRNP - ED
Surgeon Involvement
• Challenges:Challenges:– Staffing for 365
coverage– Sustainable life style– Trauma service vs.
independent practitioners
– Disruption of elective cases/office hours
– “Trauma Drop Outs”– Risk exposure/non-payer– Peer Review PI
• Solutions:Solutions:– Extender support
• Day vs. Night vs. Both
– Call stipend– Malpractice support– Partnership staffing– Block time in OR– Post Call non-clinical– Service sign-over– Non-punitive Peer
Review
Emergency Department
• Challenges:Challenges:– We know how to do
“trauma”– Turf battle– Not enough space
for Trauma bay– Mindset: not injured
vs. potential injuries– Performance
improvement
• Solutions:– One call, problem
solution– Back up for airways– Feedback of
outcomes– Highlight good cases– Support of the ED at
administrative level
Financial
• Challenges:Challenges:– Non-payer mix– Call compensation– Non-clinical staffing– Educational costs
• Solutions:Solutions:– Maximize RVU
generation– Improved care =
malpractice reduction– Increased patient
volume– Higher complexity of
cases– Trauma Extenders
support other services
– Halo effect
Orthopedics**
• Challenges:Challenges:– Consultation service– Disruption of elective
schedule/office hours– Staffing for 365
coverage– Risk exposure/non-
payer
• Solutions:Solutions:– Ortho Trauma block
time– Call stipend– Employed group– Recruitment for
private group– Malpractice support– Extender support– Trauma Service
management
Pocono Ortho Surgery- Transfers
Total operative fractures seen: 110, 95
40.9%
23.1%
1.6% 16.3%
5.2%
1.0%
5.4%
Pocono Ortho Surgery– Time to OR
Average to OR 34hr
Average to OR 18.8hr
Average LOS 4.5Average LOS 5.1
63%
75%
7%
21%18%16%
Summary• Level III’s Impact
– Hospital / Patients / Community
• Right personnel • Full commitment from administration• Partnership for success• High start up cost/Long term gain• Solutions are “institutionally
dependent”• Culture Change is the “Frog”