state Of Pennsylvania's Trauma Center Designations

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1 NASEMSO REQUEST January 19, 2009 ORIGINATOR: Juliet Geiger RN, MSN, Executive Director, Pennsylvania Trauma Systems Foundation BACKGROUND: We are moving forward with our strategic plan in Pennsylvania to develop the "ideal" trauma system. We fulfill 7 of the 8 West Criteria for an inclusive trauma system. The one we lack is "the authority to limit trauma center numbers based on community need." According to a 2004 article, five states have all 8 criteria. The states listed are Illinois, Maryland, New York, Oregon, and Washington. (Reference: The Journal of Emergency Nursing, December 2004, p ) REQUEST: My request is if any of you could share with me your state's needs assessment for how you determine trauma center placement both geographically and by trauma center level. Do you take air transport into consideration? Currently we have Level I, II, and III trauma centers. We will be discussing inclusion of Level IV's. For those of you with IV's, did you develop them at the same time as all the other levels? If not, any pearls to share regarding timing of development? RESULTS UTAH: Utah does not have specific authority to limit designation. I don't think we ever will. There are two schools of thought on these specific West criteria. Some believe there should be limitations to the number of trauma centers that are designated as proficiency of medical providers can be greatly effected. The other thought is that the designation process simply categorizes a facility's trauma capabilities allowing the triage, treatment and transfer guidelines to delineate appropriate patient destination. With all facilities designated, it allows for the guidelines and PI process to monitor the appropriate patient destination and is more indicative of an inclusive trauma system. Jolene R. Whitney, MPA, Deputy Director, Emergency Medical Services and Preparedness, Utah Department of Health NEBRASKA: We do not limit the number of trauma centers that can apply. Sherri Wren, Trauma Program Manager, Nebraska Dept. of Health & Human Services, EMS/Trauma Program ARIZONA: Arizona does not have the authority to restrict numbers and levels of trauma centers. Vicki A. Conditt, RN, Trauma System Section Chief, Bureau of Emergency Medical Services and Trauma System., Arizona Department of Health Services 1

2 DELAWARE: Hi Juliet, just a word on our L4's, we call them Trauma System Participating Hospitals and do not consider them to be trauma centers. They do not get patients meeting trauma triage scheme criteria because here they are close to TC's and patients meeting criteria can go directly to those TC's. Our PH's have to be able to recognize serious trauma that might walk in to their facility, have a trauma activation process, transfer in a timely manner to the appropriate TC, have PI initiatives to be sure the above are happening, and contribute data to our Trauma System Registry. We did our Level 1/2/3 TC's first and then focused on getting the remaining uncommitted hospitals to join in as PH's. We do our PH site visits ourselves, using an out of state physician as the team leader, with the chair of our Trauma System Designation Committee and myself as site visit team members. Let me know if you have additional questions. We currently have 3 PH's in our system. We do not limit the number of trauma centers, we have only 8 acute care hospitals to begin with!! MarySue MarySue Jones, RN, MS Trauma System Coordinator Delaware Office of Emergency Medical Services (302) MarySue.Jones@state.de.us VIRGINIA: We do not have any control over where or how many trauma centers there are in Virginia. If a hospital can pass the designation process they can be designated by our State Health Commissioner. Virginia has Level III I and uses a state designation process. We have had discussions on creating level IV centers but nothing immediately pending. Paul Sharpe, Virginia Office of Emergency Medical Services, Division of Trauma/Critical Care NEW HAMPSHIRE: New Hampshire does not have the authority to limit the number of trauma centers. Clay O Dell NORTH DAKOTA We are in the process of our legislative session and we are going for mandatory trauma designations for all our hospitals that provide emergency services Amy Eberle, RN, BSN, EMT State Trauma Coordinator, ND Department of Health, Division of EMS and Trauma COLORADO: We do not have the power to limit, but here's a thought...i don't think that at the Level IV level, you should limit. 2

3 Here's my public health rationale: Every hospital gets trauma. Every hospital keeps some trauma...even if it is the 85 year old DNR hip fracture patient. Every hospital makes life and death decisions about those trauma patients. Moreover, every hospital makes decisions about those patients that will influence the amount of disability they might live with for many years. If every hospital were required to at least be in the system, then every hospital would have to treat those trauma patients as trauma patients. They would have to look at the care they gave and decide whether they could have done better and you can hold them to it. Otherwise, they still get and keep the same (minor) trauma patients, but you never get to look at what they do with them. Not every trauma can be saved, but without a system of accountability, it is very easy for best practices to go by the wayside. Look at the 5 million lives campaign. We're talking about things like hand washing and double checking dosages of medication. Those little old ladies are going to be us some day. I want someone treating me with a view to the future, even if the future is being a little old lady who can use a walker instead of being bedridden. Grace Sandeno, MPH, Trauma Program Director Colorado Department of Public Health and Environment 3

4 MARYLAND: Our law allows MIEMSS to designate Trauma Centers based on need. Our regulations- COMAR The need is based on population, patient volume, and geographic coverage. Mary Beachley, RN, Director, HEALTH FACILITIES & SPECIAL PROGRAMS Maryland Institute for Emergency Medical Services Maryland Certificate of Need Program: From Maryland Regulations:.02 Criteria for Designation. A. The EMS Board shall: (1) Establish criteria for the number and level of trauma and specialty referral centers to be designated; and (2) For specialty referral centers that require a certificate of need from the Maryland Health Care Commission, establish the criteria for the number of specialty referral centers in coordination with the Maryland Health Care Commission. B. For each region, the criteria shall address: (1) Access to trauma or specialty care; (2) Level of care; (3) Capacity to provide the care; and (4) Timeliness of care received. C. MIEMSS may consult with appropriate State agencies in determining the need for trauma or specialty services for a hospital's geographic service area..04 Denial of Application for Designation. A. MIEMSS may deny an application for designation without conducting an onsite review if it finds that the hospital: (1) Would add unnecessary duplication of services to a geographic service area where there is not a sufficient need for additional trauma or specialty services; (2) Is unable to meet the requirements of this subtitle for the level of designation sought; (3) Makes a false statement or omits a material fact in the hospital records, documentation, or materials required to be submitted that pertain to the designation process; (4) Is less qualified than another applicant hospital in the same geographic service area; (5) Is applying for designation as a specialty center that requires a certificate of need from the Maryland Health Care Commission but does not have the required certificate of need; or (6) Should not be designated for any other relevant reason. 4

5 WASHINGTON STATE Our legislation requires our 8 EMS and Trauma Care Regional Councils to determine the number, level and distribution of trauma services needed in their region. (Most of the regions simply include every licensed hospital in the regional trauma system.) Our EMS and Trauma Steering Committee reviews the numbers and the Department of Health (DOH) has final approval. DOH retains the responsibility for determining the need for Level I (statewide) trauma services. Only one Region has limited participation in the trauma system (more hospitals than determined trauma service need). In that Region, we had to run a competitive application process (twice) because more hospitals applied than there were spots available. I've attached a document that describes the process and criteria Regions use to determine the number of services needed. Over the past several months we have been playing with a more "scientific" process for determining need and distribution. A former co-worker had developed two different algorithms - one based on population by county and the other based on trauma patient volumes - in an effort to have a more "formulaic" process for determining need and distribution. (I've attached the models for your information). We applied the models and they didn't pass the "reality" test. Unfortunately (as I'm sure you're finding) there is not much in the literature about need and distribution. Hence, we stayed with the more descriptive process and criteria in the attached document. In reality trauma services will emerge and be sustained in areas where there are resources, will - and most importantly - physicians to support them. In terms of levels - we not only have Level IV's but we have Level V's too. Originally, Level V was developed to recognize the contribution a nonhospital/clinic can play in a rural/wilderness area. As it turns out, most of our small, critical access hospitals have designated as level V. All levels were developed and implemented at the same time. Link to regional trauma plans: and%20trauma%20documents Kathy Schmitt, MPA, Research, Analysis and Data Section Office of Community Health Systems 5

6 WASHINGTON STATE Criteria and Process for Establishing Number and Level of Designated Facilities Purpose: Assure optimal number, level and distribution of trauma services consistent with state standards, available trauma care resources, and intra and inter regional trauma patient volumes. Process: The EMS and Trauma Regional Councils are responsible for establishing the number and level of trauma services needed in the region based on the criteria listed below. The minimum/maximum numbers for each level of trauma designation are included in the regional plan. The EMS and Trauma Steering committee reviews the plans, and the Department of Health approves the plans and includes the final approved regional minimum/maximum numbers in the state EMS and trauma plan. Every three years a new competitive round of trauma designation is initiated in each region. It is important that each region review the minimum/maximum numbers prior to the start of a round of designation to address any changes in the regional trauma system including new resources, changes in current resources, population changes and trauma volume changes. Department staff is available to help regions review relevant data including from the sources listed below in the minimum/maximum planning process. Criteria: The region must consider the following criteria when determining the optimal number, level, and distribution of trauma care services in the region. RCW: Availability of resources Distribution of trauma patient volume Additional System Influences: Population demographics (density, growth, etc.) Trauma patient volumes (current and forecasted) Trauma patient acuity Geographic constraints/issues Patient flow patterns Market share/use rates Balancing access with quality of care and cost. Available Data Sources: o Trauma Registry o CHARS o Death records 6

7 WYOMING: The State of Wyoming has in place a statue that requires a hospital to have a trauma system as part of their hospital licensure. We only have 27 hospitals in our entire state. We have 2 Level II s, 8 Level III s, 10 Level IV s, and 7 Level V s. We just had a new hospital open and part of their licensure process is to fill out a pre-survey questionnaire for their trauma designation visit. Each hospital decides what level they choose to attain. Sue Wilson RN BSN, Wyoming State Trauma Program Coordinator, Office of Emergency Medical Services, Department of Health OKLAHOMA Oklahoma requires mandatory classification of Emergency and Trauma Operative Services as part of the hospital licensure requirements; the carrot: up until 1/1/09, Medicaid reimbursed for all ED Medicaid patients (trauma and other ED visits) based upon the hospital classification. The stick: failure to have the resources required for the level of classification for which the hospital selfdeclared (and licensed as) results in the non-compliance process for hospital licensure. Mandatory classification, however, is the foundation for creating regional systems of trauma care: keeping patients within regions if appropriate care is available, rather than referring to the 2 largest urban areas in OK; also helped hospitals and EMS agencies within the region identify the resources available. Patrice Greenawalt, MS, RN Director, Trauma Division, Oklahoma State Department of Health 7

8 Grace Sandeno, MPH Trauma Program Director Colorado Department of Public Health and Environment (303) phone Vicki A. Conditt, RN Trauma System Section Chief Bureau of Emergency Medical Services and Trauma System Arizona Department of Health Services 150 North 18th Avenue, Suite 540 Phoenix, Arizona Jolene R. Whitney, MPA Deputy Director Emergency Medical Services and Preparedness Utah Department of Health P.O. Box SLC, Utah Highland Drive, Room cell Patrice Greenawalt, MS, RN Director, Trauma Division Oklahoma State Department of Health 1000 NE Tenth Street, Oklahoma City, OK Phone 405/ Clay O Dell, RN, EMT-P Trauma Manager NH Dept. of Safety 33 Hazen Drive Concord NH (603) F: (603) codell@safety.state.nh.us Maryland Mary Beachley, MS, RN, CNAA Trauma Manager MIEMSS 653 W. Pratt Street, Room 405 Baltimore MD (410) F: (410) mbeachley@miemss.org Sue Wilson RN BSN Wyoming State Trauma Program Coordinator Office of Emergency Medical Services Department of Health State of Wyoming Hathawy Bldg., 4th Floor Room 449 Cheyenne, WY office: (307) Susan.Wilson@health.wyo.gov Amy Eberle, RN, BSN, EMT State Trauma Coordinator ND Department of Health Division of EMS and Trauma 600 East Boulevard Ave. Bismarck ND Office: aeberle@nd.gov Website: Sherri Wren Trauma Program Manager Nebraska Dept. of Health & Human Services, EMS/Trauma Program 301 Centennial Mall South P.O. Box Lincoln, NE (402) (402) (cell) Sherri.Wren@Nebraska.gov Website: ma.htm Minnesota Tim Held State Trauma Coordinator MN Department of Health P.O. Box St. Paul MN (651) tim.held@health.state.mn.us 8

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