written comments on trauma plan and related ems policies ...€¦ · section i, ltr b 2 page 3 san...

Written Comments on Trauma Plan and related EMS Policies 45 Day Public Comment Period Ending August 15, 2012

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POLICY NO.

ORGANIZATION COMMENT RESPONSE SECTION

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Trauma Plan Section I, Ltr B 2 Page 3

San Joaquin General Hospital (SJGH)

Topic: Triage Policies The American College of Surgeons (ACS) urges that “…the prehospital triage criteria should not be finalized until after the RFP is complete and the hospital to be designated is selected”. ACS makes this recommendation to ensure that those individuals who will be involved in implementing the trauma center will have input into the triage policy, which is a key policy for the trauma system as it specifies how and where trauma patients will be managed. Although a triage policy is included in this Trauma Plan, we urge that it not be finalized until such time that a hospital is selected for designation, and that the triage policy be finalized after RFP selection but before formal initiation of the trauma system. We also urge that, consistent with ACS requirements, the selected trauma center’s Trauma Medical Director and others be included in the process to finalize the triage criteria. Recommendations: Modify Section I, B.2 as follows: “Develop draft prehospital triage, treatment, and transport protocols that reflect the urban and rural nature of the county”. The triage policies will be finalized after a hospital is selected to be the trauma center and will include the input of key participants in this process”. Recommend that the EMS Agency not finalize Policy #5210 until after a trauma center is selected and ensure that the selected trauma center’s Trauma Medical Director is included in the finalization of the triage policy.

The EMS Agency is currently reviewing comments received regarding EMS Policy No. 5210 Trauma Triage and Patient Destination. It is the EMS Agency’s intent to finalize this policy prior to submission to the EMS Authority for review. This policy as well as other EMS policies will be modified based on an analysis of the policy’s effectiveness in meeting the needs of patients. The EMS Authority has encouraged the SJCEMSA to complete and implement trauma triage criteria as soon as possible and prior to designating a trauma center in San Joaquin County. The designated trauma centers serving San Joaquin County will be heavily involved in evaluating the effectiveness of the triage policy.

Trauma Plan Draft Section 1, B. Page 3

Doctors Hospital Manteca P. Gooch

1. Who will own/manage registry? 2. Will non-trauma hospitals be required to submit data and/or

review data submitted? 3. How will patient outcomes be reported to the community

hospitals of patients transferred to Trauma Facilities?

The EMS Agency will purchase and own the central trauma registry. The selected trauma center and any other community hospital desiring to


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4. How will non-trauma hospitals trigger a trauma audit based on:

a. Issues with EMS and hospital selection for a trauma patient (i.e., under-triaged)

b. Issues in transferring patient to trauma facility

be a participant may purchase a facility version of the trauma registry and participate in the submission and analysis of trauma data. Annual and periodic reports on trauma patient outcomes will be published and made public. A community hospital may request a trauma audit by contacting the EMS Agency. Under triage will be a primary audit filter (metric) of the trauma audit committee.

Trauma Plan Draft Section 1, D. Page 4


1. Who will comprise the Trauma Advisory Committee? 2. Will non-trauma hospitals be given the opportunity to be

represented on the Trauma Advisory Committee?

To be determined. It is the intent of the EMS Agency to have non-trauma hospitals represented on the TAC.

Section 3 A. Overview 8 of 25

Manteca District Ambulance

…”resulted in 206 trauma related deaths in 2009.” Is it possible to receive more definitive data? Were these deaths out-of-hospital, called on scene, transported? Is data from 2010 and 2011 available?

The county’s morbidity data is available from San Joaquin County Public Health Services. http://www.sjcphs.org/

Section 3 A. Overview 8 of 25


…”41,373 requests for emergency medical services, 7,762 (18.8%) of these…” This number seems grossly miscalculated. Does this number only represent the number of “trauma” patients versus medical?

The denominator of 41,373 is the total EMS requests for service. The numerator of 7,762 is the number of injured patients transported. The SJCEMSA rejects the supposition that data contained in the trauma plan is “grossly miscalculated”.


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Trauma Plan Draft Section III, B. Page 8


I strongly disagree with the statement “…and admitted to intensive care units that are ill-equipped and unprepared to manage complex trauma cases.” This statement denigrates the care rendered by the ED physicians in San Joaquin community hospitals who have (for years) been caring for any and all trauma patients in the absence of a trauma system. Even though not transported initially to designated trauma centers (via EMS or POV), these patients have been treated, stabilized, and expeditiously transferred when patient condition required a higher level of care. The problem is not really with the care – the problem you are trying to correct is the absence of criteria that would establish where the patient could best be cared for. Semantics? Perhaps, but I respectfully request removal of this inflammatory statement.

Agreed, wording deleted.

Trauma Plan Section IV, Ltr B Page 9

SJGH Topic: System Design Options Under the section on system design, the Trauma Plan states the clear direction of designating a Level III center first, who commits to becoming a Level II center later. Until the Trauma System is operational, speculating about the need for additional trauma centers is premature and creates confusion. Once the Trauma System is fully implemented, the EMS Agency can make adjustments to the system design based on actual experience and data. Recommendation: Delete the second paragraph which states “Once the designated level III trauma center has fully achieved its commitment to level II designation and other verification requirements, the EMS Agency will re-evaluate the desirability of designating additional level III

No change, it is the responsibility of the SJCEMSA to continually evaluate the trauma system to ensure that patient needs are being met. This includes evaluating whether adequate trauma resources are available to treat patients.


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trauma centers in the county”.

Section 4 B.3 10 of 25


What is the goal for transport times? Are there any other variables that are included in this? (Including response times, on scene times, the “Golden Hour,” etc…)

The goal is to identify and transport major trauma patients to designated trauma centers based on established trauma service areas. It is the expectation of the SJCEMSA that prehospital personnel will expedite the transport of trauma patients keeping scene times to less than ten (10) minutes. This subject will be addressed in future revisions of the Basic Life Support (BLS) and Advanced Life Support (ALS) treatment protocols.

Trauma Plan Section IV, Ltr B, 4, a Page 11

SJGH Topic: Service Areas The Trauma Plan needs to make it clear that the designated Level III trauma center’s catchment area for adult trauma patients is all of San Joaquin County. The current language gives the impression that the catchment area is based primarily on geography because of the way the description is laid out. Recommendation for 4.a., page 11. We suggest the following wording: “The planned level III trauma center in San Joaquin County shall serve as the primary receiving facility for all adult major trauma patients in accordance with the policies established in this Trauma Plan and by the EMS Agency. For the vast majority of San Joaquin County. Exceptions (e.g., pediatric trauma patients, major burn patients, multi-casualty incidents, etc.) are listed below”.

The planned level III trauma center’s primary service area is not all of San Joaquin County. The parts of ambulance zones E and F south of Highway 120 identified in the trauma plan and related policies are geographically closer and have better access to the level II trauma centers based in Stanislaus County. The service area for isolated neurologic patients is deleted.


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Trauma Plan Section IV, Ltr B, 4. b. Page 11

SJGH Topic: Service Area – Southeastern corner of County We support sending trauma patients to designated trauma centers in Modesto for trauma patients located south of Highway 120 in Ambulance Zone E and Zone F. We believe that the area west of Highway 99 in Zone E is closer to hospitals in San Joaquin County, and should be directed to the designated trauma center in San Joaquin County. Recommendation: Add the following language to section 4.b as follows: “The level II trauma centers operating in Stanislaus County (Doctors Medical Center and Memorial Medical Center, Modesto) shall serve as the primary receiving facilities for adult major trauma patients in the southeastern portion of San Joaquin County in those portions of Ambulance Zones E and F and that portion of Ambulance Zone F south of State Route 120 and east of Highway 99”. The rest of the paragraph remains the same.

No change. The parts of ambulance zones E and F south of Highway 120 identified in the trauma plan and related policies are geographically closer and have better access to the level II trauma centers based in Stanislaus County.

Section 4 B.4.b. 11 of 25


Manteca District Ambulance requests to be included with Zone E and Zone F in order to primarily transport trauma patients to level II trauma centers operating in Stanislaus County (Doctors Medical Center and Memorial Medical Center, Modesto) until SJC has a designated level II trauma center. Doing anything less would result in a decreased level of service to the citizens of Manteca who have been utilizing Stanislaus County level II trauma centers. Manteca District Ambulance requests portions of their Zone be designated to these facilities similar to Zone F. The West side of Zone D would adopt this plan and transport to the Level III facility.

No change. Ambulance zone D which Manteca District Ambulance serves will be geographically closer and will have easier access to the planned level III trauma center.

Trauma Plan Section IV, Ltr B,

SJGH Topic: Remove reference to neurologic injuries from section on pediatric and burn trauma patients. The reference to field triage of patients with “neurologic injuries

No change. This paragraph is summarizing coordination with neighboring trauma systems and is


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4.c Page 11

without comorbid trauma located in the northern portion of San Joaquin County” should not be in this section on pediatric and burn trauma patients. Neurologic and spinal cord injured patients deserve their own section, under e. Also, the destination for neurologic patients will be different for Level III vs Level II designated trauma centers Recommendation for 4.c: Remove the sentence “The level II trauma center operated at Kaiser Hospital South Sacramento shall serve as the primary receiving facility for adult major trauma patients with neurologic injuries without comorbid trauma located in the northern portion of San Joaquin County”.

not exclusive to pediatric and burn trauma.

Trauma Plan Section IV, Ltr B, 4 b and c Page 11

SJGH

Topic: Reference to specific facilities: Remove specific reference to designated trauma centers in the Trauma Plan because these may change over time, and because agreements are not yet in place for all of the referenced centers. Instead, refer to the “closest designated trauma center in XX County with an agreement with the San Joaquin EMS Agency”. Recommendation for 4b: Remove reference to Doctor’s Medical Center and Memorial Medical Center, Modesto. Recommendation for 4c: Reword this section as follows: “Pediatric major trauma patients and major burn patients will be transported to the nearest designated trauma center in Sacramento County in accordance with EMS Agency policy and in accordance with agreements between the EMS Agency and the neighboring

No change. The references to specific facilities are accurate and appropriate.


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trauma centers. The final transport rationale and distribution of trauma patients into Sacramento County shall be developed as part of an inter-county agreement with the Sacramento County EMS Agency for the coordination of neighboring trauma systems.

Trauma Plan Section IV, Ltr B, 4c and 4e Page 11

SJGH

Topic: Neurosurgical patients We agree that trauma care for acute spinal cord injured patients and neurosurgical patients should be transferred from the field to trauma centers with a higher level of resources than is currently available in San Joaquin County. These neurosurgical and spinal cord transfers are appropriate when there is a Level III trauma center in the County. Once the Level III center is designated a Level II center, then these patients should be transported to the Level II center in the County. This section does not clearly make that distinction. Reference to spinal cord injured patients should be in 4e of this section. Recommendation to 4c: If you do not use the recommended language above, remove the reference to “and trauma patients with acute spinal cord injury. Recommendation to 4e: Reword this section as follows: “The EMS Agency anticipates that the designated level III trauma center will provide for neurosurgical trauma services through the use of written transfer agreements with higher level trauma centers. Trauma patients with acute spinal cord injury and adult major trauma patients with neurologic injuries without comorbid trauma will be transported from the field to the nearest designated neighboring trauma center based on these written transfer agreements with higher level trauma centers. In an effort to eliminate unnecessary transfers, the EMS Agency will develop

Amended to add: “Trauma triage criteria and patient destination methodologies will be re-evaluated following the successful transition of the level III trauma center to level II trauma center designation.” The service area for isolated neurologic patients and the related triage criteria are deleted.


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triage criteria to assist EMS personnel in identifying pediatric and adult major trauma patients with neurologic injuries, allowing such patients to be transported directly to a level I or level II trauma center with in-house neurosurgical trauma services. Once a Level II trauma center is designated and in-house neurosurgical services are established, the acute spinal cord injured patients and adults with neurologic injuries without comorbid trauma meeting triage criteria will be transported from the field to the designated Level II trauma center in San Joaquin County”.

Trauma Plan Section IV, Ltr B 6 Page 12

SJGH Topic: Back-up landing sites The EMS Agency should include an additional back-up plan if an emergency landing site cannot be found in the urban core of the City of Stockton. Recommendation to 6: Add language at the end of this section which states: “The EMS Agency will develop back-up plans for transport of specified patients to trauma centers outside of San Joaquin County in the event weather conditions prohibit the use of helicopters”.

No change. This paragraph is specific to air ambulance utilization. Ground ambulance is and shall remain the primary method of transport for all trauma patients regardless of destination.

Section 4 B.7 12 of 25


Will the SJCEMSA require theses trainings as mandatory curriculum or integrate them into the PSR course? Does the SJCEMSA foresee PHTLS, ITLS, or BLTS becoming mandatory for Paramedic Accreditation and or/Re-accreditation in SJC?

Trauma training will be both mandatory and incorporated into existing training programs such as Paramedic Accreditation Orientation. The EMS Agency will not require PHTLS, ATLS, BLTS, or other merit badge courses for paramedics.


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Trauma Plan Sec IV, Ltr C. 3 Page 13

SJGH Topic: Multi-Disc. Peer Review ACS standards require EMS Agencies to have a County Trauma Audit Committee (TAC) and to participate with regional audit committees. Section 3 refers to the regional participation in quality improvement activities. We recommend this section state who will be included in this regional Peer Review/QI process. SJGH prefers that San Joaquin participate with the Mountain Valley EMS Agency (MVEMSA) TAC as we have established working relationships with them. We also vigorously oppose regional TAC meetings that rotate between MVEMSA and Sacramento trauma centers because of the travel involved. Recommendation:

Modify Section C.3 such that it describes in more detail how a regional TAC would work (frequency of meetings, membership, etc.). If travel to a regional TAC is required, we recommend that it be rotated or shared with the Modesto trauma centers based on established relationships and proximity.

The organization and membership of the TAC is to be determined. The SJCEMSA is in the process of reviewing all options regarding the provision of the trauma audit process.


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Trauma Plan IV, Ltr B #9 Page 12

SJGH Topic: Base Hospital contact Current EMS policy states that the San Joaquin County Base Hospital and DCF would serve as the designated notification point for major trauma patients being distributed to trauma centers. We recommend adding that they would distribute the patients who are both inside and outside of San Joaquin County. Recommendation: Add the following: “…San Joaquin General Hospital serves as the designated notification point for major trauma patients being distributed to trauma centers located inside and outside of San Joaquin County in accordance with EMS Agency policies”.

No change required. Prehospital personnel shall transport a single major trauma patient to the appropriate designated trauma center based on its assigned service areas. Should weather, traffic, or some other unforeseen circumstance prevent such a transport the major trauma patient would be preferentially transported to the closest trauma center regardless of service area or to the closest general acute care hospital, if necessary. The Disaster Control Facility shall continue in its role of dispersing major trauma patients from multi-casualty incidents and/or incidents with multiple major trauma patients. The “how to” will be established during trauma system implementation.

Trauma Plan Draft Section IV, C. Page 14


Letter d. You should insert language in this section that would include hospital capacity/capability when decisions are made to transport to a non-designated trauma facility.

Agreed, see changes.


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Trauma Plan Draft Section IV, C. Pages 15, 16, 17


#8. I don’t understand why you need language regarding HMOs. This should not come into play in a trauma scenario, whether for first responders or transferring hospitals. It is a higher level of care transfer, regardless of payer. #9. I know this section refers to “transport” for transfers, however I am concerned with any language that gives a receiving physician any leeway to say “no” to a trauma transfer without having eyes on the patient. #14. Verbiage to assess competency and training requirements (certifications) for hospital personnel. Outlined in ACS standards, so verbiage could be “per ACS standards for appropriate level of designation”. As far as hospital personnel knowing the EMS Agency’s P&P, verbiage “as it relates to hospital operations” might be helpful. The most important field EMS policy hospital personnel need to know is the trauma transport criteria – which, once learned, will still be subject to interpretation and application. #15. I would request that any RFP application would include a detailed statement of community education related to injury prevention and other community outreach.

8. State regulations require this subject to be addressed during the trauma planning process. 9. Add: “San Joaquin County designated trauma centers are required to accept patient transfers from non-designated San Joaquin County hospitals for patients meeting major trauma patient triage criteria.” 14. Agreed, see changes. 15. Agreed. This will be addressed in the RFP process.

Trauma Plan Section IV, Ltr C Page 20

SJGH Topic: Implementation Schedule To be consistent with Policy 4710 which allows an applicant 60 days to respond to the RFP, the timeline for a site visit should be changed from January 2013 to February 2013. Recommendation: Insert “February” in place of “January” 2013 for Section VI, C. 4.

The implementation schedule uses projected completion dates. The timeframes included in EMS Policy No. 4710 Trauma Center Designation shall be adhered to during the process.


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Trauma Plan Sect VI, Ltr F Page 20

SJGH Topic: Typographical Error There is a typo on Section VI., F which currently references a Level II trauma center by July 2013. Recommendation: Change to “....Level III trauma center”.

Change made.

4701 III A 2

Mountain-Valley EMS Agency

There are existing Trauma Advisory Committees in neighboring counties that would welcome SJ County into their respective meeting environment. The discussions and peer review from multiple trauma centers would benefit all.

SJCEMSA appreciates the willingness of the MVEMSA to welcome SJC into its existing trauma audit committee process. SJCEMSA agrees that partnering with a neighboring trauma system may be a good option for system participants and patients. We will be contacting you to discuss the possible integration of our trauma audit processes.

4701 IIIA 2

Merced County EMS

Recommend joining an existing TAC with multiple trauma centers rather than inviting other hospitals to yours. As a peer-review process the more external surgeons at the table, the better discussions you will have regarding cases with Opportunities For Improvement.



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4701 IIIA 2

Memorial Medical Center, Modesto

Recommend joining an existing TAC with multiple trauma centers rather than inviting other hospitals to yours. You will have a better discussion for OFI with a established TAC group.


4701 IIIA 2

Doctors Medical Center, Modesto

Suggest joining an existing TAC with multiple Trauma Centers, you will have better discussion for opportunities for improvement.


4701 V A 2

Merced County EMS

Recommend adding “once patient is discharged from ICU” and “transferred to a HMO member hospital with appropriate services to meet the patient’s ongoing needs during the sub-acute phase”. We have had a lot of trouble with a certain HMO.

Agreed. See change.

4701 V A 2


Recommend adding “once patient is discharged from ICU” and “transferred to a HMO member hospital with appropriate services to meet the patient’s ongoing needs during the sub-acute phase”.

Agreed. See change.

4701 VI A 3

MVEMSA There’s a bracket after “courses” in the middle of the sentence that has been misplaced.

Corrected.


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Trauma Plan EMS Policy 4709, Def: A & D Page 1 of 2

SJGH Topic: Definition of a Pediatric patient The age definition of a pediatric patient is inconsistent between sections A and D. It is generally established that the adult patient is a patient greater than 15 years of age and the Pediatric patient is a patient less than 15 years of age. This captures the patients without losing a year in the interpretation. Recommendation: Modify Section D as follows: “Pediatric major trauma patient” means a patient less than 15 14 years of age or younger that meets one or more of the major trauma triage criteria”.

The definition for adult major trauma patient is unnecessary and will be deleted.

Trauma Plan

EMS Policy 4709 – Policy section, III, Ltr A

Page 2 of 2

SJGH Topic: Role of Level III trauma center The use of the word “isolated” in subsection A can be confusing. Use the same language in the Trauma Plan to be consistent. Recommendation to III.A Remove the word “isolated” and replace it with “…neurologic injuries without comorbid trauma and/or burn injuries:

Agreed. See changes.

4709 IV and V 2

MVEMSA Modesto Level II Trauma Centers have the capabilities in place to care for spinal cord injuries.

No change. The infrequency and complexity of isolated spinal cord injuries along with the proximity to and availability of the services of a level I trauma center make the U.C. Davis Medical Center the appropriate destination.

4709/ Trauma plan IV and V/4c

Merced County EMS

DMC and MMC are capable of caring for spinal cord injuries. Recommend transport to Stanislaus County

No change. The relative infrequency and complexity of isolated spinal cord injuries along with the proximity


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2/11 to and availability of the services of a level I trauma center make the U.C. Davis Medical Center the appropriate destination.

4709 IV and V 2

Memorial Medical Center, Modesto Doctors Medical Center, Modesto

DMC and MMC are capable of caring for spinal cord injuries. Recommend transport to Stanislaus county if south of Eight Mile Rd and UCD North of Eight Mile Road

No change. The infrequency and complexity of isolated spinal cord injuries along with the proximity to and availability of the services of a level I trauma center make the U.C. Davis Medical Center the appropriate destination.

4709 V C and VI A 2

Merced County EMS

Recommend using a GCS less than or equal to 8 to triage neuro patients to Level II centers.

EMS Policy No. 4709 addresses service areas; trauma triage criteria are addressed in EMS Policy No. 5210. GCS is purposely not used as the sole criteria for identifying neurologic injured patients. Our intent is better served by using both a GCS component along with the two types of neurological injuries listed to identify patients that must be transported to a Level II trauma center. A GCS of less than or equal to 8 fails to account for all of the patients with comorbid trauma that may or may not be evident in MVCs. Such patients will be transported to the San Joaquin County designated trauma center.


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4709 V C and VI A 2


It would be easier on the medics to use a GCS less than or equal to 8 to triage neuro patients to Level II centers. I recommend you look at Central California EMSA field triage guidelines as they have a Level III in their system and I believe this is how they triage to their Level II and I centers.

EMS Policy No. 4709 addresses services areas; trauma triage criteria are addressed in EMS Policy No. 5210. GCS is purposely not specified in EMS Policy No. 5210 because our intent is better served by listing the two types of neurological injuries that must be transported to a level II trauma center. A GCS of less than or equal to 8 fails to account for all of the patients with comorbid trauma that may or may not be evident in MVCs. Such patients will be transported to the San Joaquin County designated trauma center.

4709 IV 2

Merced County EMS Memorial Medical Center, Modesto

I would consider Oakland Children’s hospital as another pediatric option. Zone E and F and south of Hwy 120 are closer to OCH than UCD. In the winter air ambulance has a hard time reaching UCD due to fog. In the summer it is hard to get into the bay because of fog. Always good to have the options and has worked well for MVEMSA.

The proximity to and availability of the services of a level I pediatric trauma center make the U.C. Davis Medical Center the appropriate destination from the field care setting. The intended level III may enter into an agreement with Oakland Children’s Hospital or any other pediatric trauma center to expedite the transfer of pediatric major trauma patients.

4709 IV 2


Oakland Children’s hospital should be considered for an additional Pediatric Trauma Facility. They are closer to some portions of your county and is [sic] good to have an additional Pedi Center when weather issues can be an issue.

The proximity to and availability of the services of a level I pediatric trauma center make the U.C. Davis Medical Center the appropriate


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destination from the field care setting. The intended level III may enter into an agreement with Oakland Children’s Hospital or any other pediatric trauma center to expedite the transfer of pediatric major trauma patients

Trauma Plan

EMS Policy 4709 Sect. V, Ltr. B

Page 2 of 2

SJGH Topic: Service area southeast of county

We believe that the area west of 99 and south of Highway 120 in Ambulance Zone E is closer (based on time and road conditions) to San Joaquin County hospitals. It should be included in the trauma service area for San Joaquin County, and not be transported to Modesto trauma centers. For example, if an incident occurs on Hwy. 99 at Ripon it takes less time to travel to SJGH, traveling on freeways, instead of having to wind through Modesto, especially during commute hours. From Hwy 99 in Ripon, the distance to SJGH is 18.4 miles but takes only 20 min. vs. Hwy 99 to Memorial Medical Center which is 11.7 miles but takes 21 minutes in non-commute traffic.

Recommendation:

Modify Section B as follows:

“Primary service area: The area All of San Joaquin County except for the area south of State Highway 120, in San Joaquin County Ambulance Zones E and F; east of 99, in San Joaquin County Ambulance Zones E and F and the area within the city limits of Escalon.

No change. The planned level III trauma center’s primary service area is not all of San Joaquin County. The parts of ambulance zones E and F south of Highway 120 identified in the trauma plan and related policies are geographically closer and have better access to the level II trauma centers based in Stanislaus County. The service area for isolated neurologic patients and the related triage criteria are deleted.


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4710 V. Page 2


D. Comprehensiveness. Seems overly broad and open to wide interpretation. I think letter E. covers D., if that makes sense, in that you want them to demonstrate their program meets their plan’s statements.

Agreed. Item D is deleted.

4712 II 3


C. Achieved accreditation as opposed to “possess” – semantics yes…but it is an achievement. Trust me. E. TYPO “Surgeons”

Amended, see change.

4712 & 4713 A 1

MVEMSA Merced County EMS Memorial Medical Center, Modesto Doctors Medical Center, Modesto Doctors Hospital Manteca P. Gooch

“…available for consultation by telephone within thirty (20) minutes.” Need to make them both twenty.

Corrected


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EMS Policy 4713, Purpose and Def: Ltr. F Page 1 of 9

SJGH Topic: Typographical error There is a typographical error on the Purpose Section of policy 4713. It lists Level II when it should be Level III. Recommendation: Change “…..to establish the minimum standards for level II trauma center designation…” to Level III trauma center.

Corrected.

EMS Policy 4713, Policy, II, Ltr. E

Page 3 of 9

SJGH Topic: ACS Verification The requirement that a Level III center obtain and maintain ACS trauma center verification within a year of designation is too short of a time period and may be an unnecessary cost. A more practical, less costly mechanism to provide an independent review of San Joaquin’s designated center’s trauma capabilities would be to have a consultation visit by the American College of Surgeons (ACS). A formal ACS verification can be done once Level II status is achieved by the Level III center (this is already in the Level II policy). This change in policy 4713 for a Level III center allows the designated trauma center to focus its resources and energies towards Level II status, yet provides the EMS agency with an independent review. Recommendation to II. E. of Policy 4713 Change the wording as follows: “Obtain within one (1) year of Level III designation by the SJCEMSA an American College of Surgeon Committee on Trauma (ACS-COT) consultation visit. ACS recommendations will be shared with the SJCEMSA and be implemented within six months of receipt of the report And continuously maintain thereafter, American College of Surgeon Committee on Trauma (ACS-COT) level III trauma center verification”.”.

This requirement is modified as follows: E. Obtain within one (1) year of Level III designation by the SJCEMSA an ACS-COT consultation visit. The ACS-COT recommendations shall be provided to the SJCEMSA within ten (10) days of receipt. The level III trauma center shall implement all of the ACS-COT recommendations within six months of receipt of the report. F. Obtain within two (2) years of designation by the SJCEMSA, and continuously maintain thereafter ACS-COT Level III trauma center verification. The designated Level III trauma center may request that the SJCEMSA modify or waive this requirement if the designated Level III trauma center is in substantial compliance with its designation


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agreement and is actively engaged in seeking level II designation.

EMS Policy 4713,

Section IV, C. 2

Page 6 of 9

SJGH Topic: Use of CRNAs There are certified registered nurse anesthetists (CRNAs) who are very capable of providing excellent trauma care. We feel CRNAs can provide quality trauma are at a cost effective price, and should be available to provide trauma care while on call, without the requirement that a MD be present during surgeries. California now allows CRNAs to work as licensed independent practitioners, if authorized by a hospital’s medical staff. It is our understanding that the EMS Agency and the California EMS Commission can grant a waiver from the requirement that a MD be present during surgeries where a CRNA initiated care on a trauma patient. Recommendation: Request that the EMS Agency explore this option to waive the requirement that a MD be present on trauma cases initiated by CRNAs. If it is allowed, change the wording of C.2 a as follows: “In such cases, the staff anesthesiologist on call shall be advised about the patient, and be promptly available at all times, and be present for all operations unless waived by the SJCEMSA and the California EMS Authority”.

No change at this time. The SJCEMSA is discussing the possibility of a waiver to this state regulatory requirement with the EMS Authority.


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Trauma Plan EMS Policy 4713, Policy, V, Ltr. B.2 Page 7 of 9

SJGH Topic: Use of phlebotomists We question the requirement to have a phlebotomist in house 24/7 as the nurses are quite capable of drawing blood samples which are immediately sent to the laboratory for testing. Internal studies have shown that a single phlebotomist may be slower than having nurses draw blood, as a single individual cannot respond as quickly as having multiple nurses who can draw blood samples. In addition, having a phlebotomist in house is not a requirement of either Title 22 or ACS. Recommendation: Change this section as follows: “Clinical laboratory services staffed with clinical laboratory scientist and staff capable and trained to provide immediate laboratory services for drawing blood samples phlebotomist in house.

Requirement deleted.

EMS Policy 4720 Section I under Policy Page 1 of 1

SJGH Topic: Policy on trauma center team activation The designated trauma center should have the primary responsibility for developing its policy describing the tiered response to trauma cases. This policy should be approved by the SJCEMSA to ensure it is consistent with EMS Agency policies. Currently, the wording in this section is confusing. Recommendation to section on Policy: We recommend the following wording for subsection I under Policy: “The designated trauma center shall develop a written policy describing a tiered response for activating trauma team members. This policy shall be consistent with EMS Policy No. 5215 and be approved by the SJCEMSA assist the SJCEMSA in developing tiered response criteria for trauma team members. In the absence of an SJCEMSA policy authorizing a tiered trauma team response designated trauma centesr shall ensure a full trauma team

Agreed. See changes.


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response, including the attending trauma surgeon, to the trauma resuscitation area or patient bedside upon the receipt of a trauma center notification from prehospital personnel per EMS Policy 5215, Trauma Center Notification”.

5210 III 2

Merced County EMS Memorial Medical Center, Modesto Doctors Medical Center, Modesto

Most of the state is adopting the 2011 CDC Guidelines for Field Triage of Injured Patients. If transporting to Stanislaus county and Sacramento County I would look at adopting the same field treatment guidelines for consistency.

No change at this time. The EMS Agency is concerned about over triage and its impact on the planned level III trauma center. The EMS Agency along with the trauma audit committee will be evaluating the effectiveness of the triage criteria and shall make adjustments as needed. The service area for isolated neurologic patients and the related triage criteria are deleted.

5210 ALL


I appreciate all of the knowledge and preparation that went into preparing the trauma criteria. I do feel it is a bit cumbersome to the field paramedic, and quite complicated. I respectfully submit making it more simple to follow. Below is the criteria we worked on and adopted in our mature trauma system in Texas. It is based on ACS standards and the language leaves little room for medic interpretation… PRE‐HOSPITAL TRAUMA PATIENT CATEGORIZATION Level I (one) Trauma Patient: Transport to a Trauma Center with lights & sirens. Contact Trauma Center enroute. Expect Trauma Team Activation.

No change at this time. The EMS Agency is concerned about over triage and its impact on the planned level III trauma center. The EMS Agency along with the trauma audit committee will be evaluating the effectiveness of the triage criteria and shall make adjustments as needed. The service area for isolated neurologic patients and the related


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Criteria: Any trauma patient who meets any of the following criteria: • Airway – Respiratory Compromise/obstruction and/or intubation. Uncontrollable airway ‐ in a rural or frontier area the patient may be diverted to the closest appropriate facility. • Breathing – Respiratory rate of less than 10/min. or greater than 30/min. • Circulation – Systolic BP less than 90 mm/Hg. Vital sign changes associated with trauma. • Disability – GCS 13 or less. OR has any of the following injuries: • Any penetrating injury to the head, neck or torso. • Any gunshot wound proximal to the knee or elbow. • Flail chest. • Two (2) or more proximal long bone fractures. • Limb paralysis. • Amputation proximal to the ankle or wrist. • Unstable pelvic fractures. • Open depressed skull fractures. Level II (two) Trauma Patient: Transport to Trauma Center without lights and siren. Contact Trauma Center enroute. Patients with no level I criteria, but with the following mechanisms of injury: • Ejection from vehicle • Extrication > 20 minutes • Falls greater than 20 feet • Unrestrained rollover MVC • MVC with speed > 40 mph

triage criteria are deleted.


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• Occupied passenger space intrusion > 12 inches • Auto versus Pedestrian > 5 mph • Motorcycle collision > 20 mph and/or separation • Burns meeting Level II criteria • Death of passenger from same vehicle (not ejected) Level III Trauma Patient: Transport without lights and siren to patient’s choice of hospital. Stable trauma patients not meeting Level I or Level II criteria.

EMS Policy 5210, Section III, Ltrs. A – C Page 2 of 5

SJGH Topic: Major Trauma Triage Criteria: In accordance with the ACS criteria, we believe the triage criteria/policy should remain in draft form until after a trauma center is selected, through an RFP process. The key medical staff involved in the selected trauma center should provide input to the EMS agency on the finalization of the triage policy Recommendation: Keep policy 5210 on triage criteria in draft mode until a trauma center is selected, and finalize prior to implementation of the trauma system.

The EMS Agency is currently reviewing comments received regarding EMS Policy No. 5210 Trauma Triage and Patient Destination. It is the EMS Agency’s intent to finalize this policy prior to submission to the EMS Authority for review. This policy as well as other EMS policies will be modified based on an analysis of the policy’s effectiveness in meeting the needs of patients. The EMS Authority has encouraged the EMS Agency to complete and implement trauma triage criteria as soon as possible and prior to designating a trauma center in San Joaquin County. The designated trauma centers serving San Joaquin County will be heavily involved in evaluating the effectiveness of the triage policy.


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EMS Policy 5210 Section IV.C. and D. Page 3 of 5

SJGH Topic: trauma triage and patient destination Based on the trauma plan, adult major trauma patients and pediatric patients should be sent to the closest trauma center based on EMS Agency policies or base hospital direction. It is best to use consistent language with the Trauma Plan. Recommendation: C. Change to “Adult major trauma patient – closest trauma center based on SJCEMSA policies assigned trauma service area or base hospital direction”.

D. Change to “Pediatric major trauma patient – closest pediatric trauma center based on SJCEMSA policies assigned trauma service area or base hospital direction”.

E.

No change. The trauma plan provides a summary of the triage and transport process while EMS Policy No. 5210 provides the details of how that is to occur. There is no inconsistency.

5210 VB 3


Again, DMC and MMC are capable of caring for neuro and SCI patients. I think it would be easier for the medics to use a GCS of less than or equal to 8 rather than what is listed in b. and c. We had initially tried GCS motor score and had to many under triaged patients.

GCS is purposely not used as the sole criteria for identifying neurologic injured patients. Our intent is better served by using both a GCS component along with the two types of neurological injuries listed to identify patients that must be transported to a Level II trauma center. A GCS of less than or equal to 8 fails to account for all of the patients with comorbid trauma that may or may not be evident in MVCs. Such patients will be transported to the San Joaquin County designated trauma center.


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5210 VB 3


DMC and MMC are capable of caring for neuro and SCI patients. GCS is purposely not used as the sole criteria for identifying neurologic injured patients. Our intent is better served by using both a GCS component along with the two types of neurological injuries listed to identify patients that must be transported to a Level II trauma center. A GCS of less than or equal to 8 fails to account for all of the patients with comorbid trauma that may or may not be evident in MVCs. Such patients will be transported to the San Joaquin County designated trauma center.

EMS Policy 5210 Section V.C. 1. Page 3 of 5

SJGH Topic: Proximity to Non-assigned trauma center This section gives prehospital personnel the latitude to not proceed to a designated trauma center if the estimated ground transport time to a non-assigned trauma center is within 10 to 15 minutes” and the base hospital agrees that there is benefit to the patient to divert to the non-assigned trauma center. This statement is not needed because 1) a base hospital can already make this judgment to divert a patient away from a trauma center if the risks and benefits favor the patient; 2) it is more beneficial for a patient to be taken to a trauma center which is organized to care for his/her injuries, versus a non-assigned hospital who is not organized, even though it may take 5 to 10 minutes more to get to the trauma center. That is the purpose of having trauma centers; and 3) San Joaquin County’s transportation plan of exclusive zones makes it possible to reach a designated trauma center within reasonable times 90% of the time.

Base hospitals do not operate independently of the medical control policies of the SJCEMSA. This section of EMS Policy No. 5210 is written to authorize the base hospital to order prehospital personnel to transport a major trauma patient to a designated trauma center closer to the scene of the emergency rather than to the designated trauma center assigned by this policy, e.g. the base hospital orders a pediatric patient to be transported to the designated level III trauma center rather than to the pediatric trauma center at the U.C.


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Recommendation: Eliminate Section C.

Davis Medical Center.

5210 E 1 4

MVEMSA Per our discussion earlier – SJGH DCF communicates with Stanislaus County’s DCF for distribution of trauma patients

Details to be addressed as part of an inter-county agreement consistent with the OES Region IV Multi-casualty Incident Plan adopted by our member counties.

5210 E1 4


The DCF at SJGH will need to communicate with the DCF in Stanislaus and Sacramento counties for distribution of trauma patients.


5210 VE1 4


It is imperative that the DCF at SJGH communicates with the DCF in Stanislaus and Sacramento counties when distributing trauma patients.


5210 E2 4


MVEMSA has added re-triage of trauma patients to field trauma triage guidelines for MCI’s as many trauma patients were going to non-trauma centers then being transferred several hours later delaying definitive care. This has been a positive corrective action from MCIs in 2011.

Agree. At a minimum this issue will be addressed during mandatory training.


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5215 I 2

Merced County EMS Memorial Medical Center, Modesto Doctors Medical Center, Modesto

The DCF at SJGH need to communicate with the DCF in Stanislaus and Sacramento counties for patient distribution and destination.


6710 II C 1

MVEMSA If SJCEMSA chooses to have their trauma center participate in a joint TAC with bordering counties - language should be added to address that participation

SJCEMSA appreciates the willingness of the MVEMSA to welcome SJC into its existing trauma audit committee process. SJCEMSA agrees that partnering with a neighboring trauma system may be a good option for system participants and patients. SJCEMSA will be contacting MVEMSA to discuss the possible integration of trauma audit processes.

6720 IV 1


CEMSIS requires the following to be included in the registry …”§1797.199 of the Health and Safety Code required a “standardized reporting of trauma patients to local trauma registries” by July 1, 2003. The Commission on EMS approved the following minimum trauma patient criteria for reporting trauma patients to local trauma registries: ICD-9 800-959.9 AND Physically evaluated by trauma or burn surgeon in the ED or resuscitation

EMS Policy No. 6720, Trauma Data Management is not inclusive as it is intended to set the minimum data to be entered into the trauma registry. Once selected the SJCEMSA will work with the designated trauma center to adjust data requirements. Participation in CEMSIS and


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area OR Death in Emergency Department OR Transfer for trauma services (note: may include inter-facility and intra-facility) Exclusion: Isolated burn without penetrating or blunt mechanism of injury”

CEMSIS trauma are optional.

6720 IV 1


Refer to CEMSIS which requires the following to be included in the registry: “ICD-0 800-959.9 AND physically evaluated by a trauma or burn surgeon in the ED or resuscitation area OR death in the ED OR transfer for trauma services… Exclusion: Isolated burn without penetrating or blunt mechanism of injury.”

EMS Policy No. 6720, Trauma Data Management is not inclusive as it is intended to set the minimum data to be entered into the trauma registry. Once selected the SJCEMSA will work with the designated trauma center to adjust data requirements. Participation in CEMSIS and CEMSIS trauma are optional.

6720 V 3

MVEMSA Merced County EMS Memorial Medical Center, Modesto

Data should be submitted to NTDB annually as per ACS requirements. This helps to keep data validated, up-to-date, and with common definition.

State regulations do not require submission of trauma registry data to the National Trauma Data Bank. However, the designated trauma centers may have to submit such data as a requirement of ACS-COT verification.

6720 V 3


Data must also be submitted to NTDB annually as per ACS requirements.

State regulations do not require submission of trauma registry data to the National Trauma Data Bank.


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However, the designated trauma centers may have to submit such data as a requirement of ACS-COT verification.

GENERAL COMMENT


Has any consideration been given to allowing an “in pursuit” period where the hospital (or hospitals) who can show basic requirements would be allowed to act as a “level 2” while they fine tune their processes and gather information to show outcomes? In addition, I haven’t seen it yet – but all hospitals gather outcome and performance improvement information – will you be asking for outcomes as they relate to trauma patients? (Either during the in pursuit period or for their application for the RFP)

A hospital may provide the services for which they are licensed and capable of providing including those service traditionally associated with a level II trauma center services. However, a hospital cannot advertise or profess to provide a level of service it is not so designated to provide, e.g. level II trauma service. The designated trauma center is required by statute and EMS policy to participate in a robust trauma audit process and submit outcome data to the EMS agency. The SJCEMSA will encourage all of the hospitals in the county to participate in the trauma system by submitting data to the central trauma registry operated by the SJCEMSA.

GENERAL COMMENT

MVEMSA Development of a Trauma Center Bypass Policy? It is the intent of the SJCEMSA address hospital diversion, trauma patient diversion, and ambulance off load times as part of the RFP and contract process.

written comments on trauma plan and related ems policies ...€¦ · section i, ltr b 2 page 3 san...

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