Why Do We Need Trauma Systems The San Diego Experience

Transcription

1 Why Do We Need Trauma Systems The San Diego Experience Raul Coimbra, MD, PhD, FACS The Monroe E. Trout Professor of Surgery Executive Vice-Chairman Department of Surgery Chief, Division of Trauma, Surgical Critical Care, and Burns University of California San Diego School of Medicine

2 Trauma is a Disease

3 Epidemiology: National Trauma Data Bank

4 Injury Epidemiology Leading cause of death of Americans ages th leading cause of death for all ages Prevalent in younger people 145,000 deaths in the USA/year One third of potential life lost years before age 65. Greater than cancer and heart disease combined.

5 Injury Epidemiology Falls leading cause of death >age 65 MVA s most common cause of death ages 1-64 Fatality rates: high for firearms High complications: TBI and Spinal Cord Injury 68%: unintentional 34% of deaths: intentional

6 Economic Burden 10%-12% OF TOTAL United States medical expenditures Acute Care + Rehabilitation + lost wages + productivity = $225 billion/year

7 Impact on Hospitals 200 hospital visits per death 42 million visits in 2004 (14.4/100 persons) 38% of all ED visits 40%: unintentional falls, MVA s, struck by object or person

8 What is available to attack this epidemic disease? Pre-hospital Systems Trauma Centers Rehabilitation hospitals Trauma Systems Is this enough?

9 Trauma Care System The locally coordinated approach to swift identification of injured persons and subsequent transportation to optimal care. "Ideally, trauma care systems provide a continuum of care including prevention, pre-hospital care, acute care, and rehabilitation" Trauma care systems, CDC 1992 Early: Trauma Centers Lethal: Prevention strategy Acute care research strategy

10 Significant Accomplishments Paramedic Training Regional EMS systems 911 ATLS Trauma Care standards Verification National Trauma Data Bank TQIP Disease Management Model

11 The Infrastructure

12 The National Study on Costs and Outcomes of Trauma Center Care NSCOT 25% - Mortality Reduction <55 Organization matters in trauma care

13 Trauma Centers in the United States All Levels Level I & II Level III-V The Plotted Challenges by Hospital ZIP Code JAMA 2003

14 The Paradigm Bleeding or perforated bowel Both need intervention No intervention; delayed intervention Patient dies - preventable death

15 Does It Prove Efficacy of System? System definition transport, rapid assessment, surgical intervention Outcome fewer people bleeding to death Answer YES

16 Establishing a Trauma System Stakeholders have to be involved Needs assessment Authority Legislation Funding

17 Trauma System Initial Steps

18 Inclusive System

19 Trauma System Pre - hospital medical direction Authority Specific protocols Communication Public access guidelines 911 Dispatch protocols Scoop and Run No doctors in the ground ambulances

20 Trauma System Triage Guidelines Definition of trauma patient Categorization of facilities Triage criteria Transport Service area boundaries

21 San Diego Trauma System A Public Private Partnership Scripp s Mercy Sharp Memorial Palomar Medical Center County Health EMS Scripp s Memorial Children s Hospital UCSD Medical Center

22 San Diego County CNS & Non CNS /90 Preventable Deaths (Amherst Study) System Current rate < 1% /112 (3m) Preventable 11/541 Preventable

23 Evidence Registry MTOS Comparison San Diego County Performance Sickest patients do better than national comparative data

24 San Diego County 625 Deaths Scene T I M E DOA <6hr 6-24hr 1-2 day 2-3 day 3-4 day 4-7 day Secondary brain injury Six hours critical time frame for bleeding >7 day # pts. Shackford,1993

25 UCSD: Time to Death 900 Patients Very early, less than 2 hours deaths bleeding Head Injuries Few deaths after six hours Tot Blt Pen Hours following injury Acosta,1998

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28 TRAUMA CATCHMENT AREAS County of San Diego #Y Palomar Medical Center N Tra um a C atch me nt A rea s Mercy Pa lo ma r Scripps Sh arp UCS D Scripps Memorial Hospital, La Jolla Sharp Memorial Hospital University of California, San Diego Medical Center Children's H ospital's catchment area s ervices the entire county Miles #Y #Y #Y Children's Hospital and Health Center Scripps Mercy Hospital and Health Center S ource : Co unt y of Sa n D ie go, Hea lt h a nd Hum an Se rvices Ag ency, D ivision of E me rgen cy M edical S ervice s, A ugu st 20 01

29 Trauma Center Acute care facility Designation standards Data collection Quality improvement protocols Cost efficiency protocols UCSD Level 1 Trauma Center

30 Trauma Center ALL departments Trauma Surgeon Other physicians Critical care Neurosurgery Orthopedics Plastics and ENT Anesthesia Radiology Nurses Every other staff member

31 Trauma Center - Followup Rehabilitation UCSD Trauma Recovery Project Federally funded Long term assessment Current NIH sponsored drug intervention trial

32 Trauma Center Information systems Routine reporting Linked data: state, national Supports Operations Utilization Prevention Research

33 Monitoring a Trauma System Medical audit committee Patient s trust trauma centers are good Monthly Assessment of all Care Strengths Cooperation, exchange of ideas Weaknesses Questionable effect individual doctor Focus is on outcome - not process

34 Provider Errors Analysis Inadequate standard care Injury pattern masked missed injuries Inadequate injury severity recognition Diagnostic interpretation error Error in prioritizing order of workup

35 Quality Assurance - One Way

36 Quality Improvement Today Evidence Based Medicine Evidence Based Guidelines Systematic analysis of best practice

37 Evidence Based Guidelines

38 Trauma Systems Acute Care Improvements Improved pre-hospital airway control CT and Ultrasound Non operative management Damage control Reconstructive surgery Improvements ICP/CPP control Protective ventilation Resuscitation Blood substitutes Inflammation manipulation Enteral feeding DVT prophylaxis

39 New Outcomes Consistency and error reduction How often you do what you say you do Guidelines and Critical Pathways Decrease variability Increase quality Decrease cost

40 UCSD Level 1 Trauma Center Teaching Research Leadership Prevention Public outreach

41 Education Traditional Medical Students Residency Training Fellowship Training New Horizons International partners Courses Fellowships

42 Trauma Center Research Research Acute care Traditional focus - basic science Outcomes and process Clinical research Prevention

43 The American Public s Views of and Support for Trauma Systems Survey Conducted for: The Coalition for American Trauma Care March 2, 2005

44 Most Americans fail to identify injury as the leading cause of death for children under 10, youth 10-18, and young adults age. % indicating the leading cause of death for Americans : Non-Injury Causes Under 10 years 61% Years 56% years 67% Q520 Which of the following do you think is the leading cause of death for children in America under age 10? Q525 Which of the following do you think is the leading cause of death for adolescents in America between ages 10 and 18? Q530 Which of the following do you think is the leading cause of death for adults in America between ages 19 and 34? Base: All respondents (N=1000) Note: Q520 and Q525 do not ask about heart disease and Q530 does not ask about birth defects.

45 Motor vehicle crashes are overwhelmingly identified as the leading cause of injury-related death. % indicating the leading cause of injury related death is : 80% Q535 Which of the following do you think is the leading cause of injury related death? Base: All respondents (N=1000)

46 About two thirds of Americans are extremely or very confident that they would receive the best medical care if they had a serious or life threatening injury. % indicating how confident they are that they would receive the best medical care for their particular injury if they had a serious or life-threatening injury: 63% Q720 If you had a serious or life-threatening injury, how confident are you that you would receive the best medical care for your particular injury? Would you be Base: All respondents (N=1000)

47 Almost all Americans feel it is extremely or very important to be treated at a trauma center in the event of a life-threatening injury (after hearing a description of a trauma center). % indicating how important it would be to be treated at a trauma center if they or a family member had a serious or life-threatening injury: 94% Trauma centers are selected hospitals that provide a full range of care for severely injured patients 24 hours a day, seven days a week. This trauma care includes ready-to-go-teams that perform immediate surgery and other necessary procedures for people with serious or lifethreatening injuries, for example, due to a car accident, burn, bad fall, or gunshot. Not sure 1% Q605 If you or a family member had a serious of life-threatening injury, how important would it be to be treated in a trauma center? Base: All respondents (N=1000)

48 About nine in ten Americans think it is extremely or very important for an ambulance to take them to a trauma center in the event of a life-threatening Injury, even if it is not the closest hospital. % indicating how important it would be taken by ambulance to a trauma center even if it were not the closest hospital: 87% Not sure 1% Q610 If you or a family member had a serious of life-threatening injury, how important would it be to be that an ambulance be instructed to take you to a trauma center able to handle your specific injury, even if it is not the closest hospital? Base: All respondents (N=1000)

49 About one in three Americans believe that the hospital nearest to them is a trauma center. (Less than 8% of hospitals have a trauma center) % who believe there is a trauma center in their state and that the hospital nearest to them is a trauma center: Not asked 3% Q635 Is the hospital nearest to you a trauma center? Base: Respondents who believe there is a trauma center in their state (N=967), recalculated to all respondents (N=1000)

50 Nine in ten Americans feel that having a trauma center nearby is equally or more important than having a library. % indicating that compared to a having a public library, a trauma system is : 89% Q617 Is having a trauma center within easy reach of where you live more important, equally important, or less important that having a public library? Base: All respondents (N=1000)

51 Eight in ten Americans indicate that having a trauma center nearby is equally or more important than having a fire department. % indicating that compared to a having a fire department, a trauma system is : 83% Not sure 1% Q618 Is having a trauma center within easy reach of where you live more important, equally important, or less important that having a fire department? Base: All respondents (N=1000)

52 Eight in ten Americans feel that having a trauma center nearby is equally or more important than having a police department. % indicating that compared to a having a police department, a trauma system is : 83% Not sure 1% Q619 Is having a trauma center within easy reach of where you live more important, equally important, or less important that having a police department? Base: All respondents (N=1000)

53 Six in ten Americans would be extremely or very concerned if they found out there was no trauma center within easy reach of where they live. % indicating how concerned they would be if they found out there was no trauma center within easy reach of where they lived: 62% Q650 If you found out that there was no trauma center within easy reach of where you live, would you be extremely concerned, very concerned, somewhat concerned, not very concerned, or not at all concerned? Base: All respondents (N=1000)

54 Three fourths of Americans would be extremely or very concerned if they learned trauma centers in their state were closing or reducing services. % indicating how concerned they would be if they found out trauma centers in their state were closing or reducing services: 74% Q625 If you found out that trauma centers in your state were closing or reducing services, would you be extremely concerned, very concerned, somewhat concerned, not very concerned, or not at all concerned? Base: All respondents (N=1000)

55 A large majority of Americans feel it is extremely or very important for people in rural areas to have the same access to trauma care as do people in urban or suburban areas. % indicating how important it is that people in rural areas have the same access to trauma care as people living in urban or suburban areas: 79% Q715 How important is it that people in rural areas have the same access to trauma care as people living in urban or suburban areas? Would you say it is Base: All respondents (N=1000)

56 Three quarters of Americans believe there is a trauma system in place in their state. % who believe there is a trauma system in place in their state: Q725 To the best of your knowledge, is there a trauma system in place in your state? Base: All respondents (N=1000)

57 Nearly eight in ten Americans would be willing to pay a dime or more per year to have trauma centers and systems in their state. Over half would be willing to pay $25 or more. % indicating how much they would be willing to pay per year to have trauma centers and a trauma system in their state ready to provide care if they or their families were seriously injured: 78% 55% Not sure Decline to answer Q735 How much would you be willing to pay per year to have trauma centers and a trauma system in your state ready to provide care to you and your family if you were seriously injured? Base: All respondents (N=1000) 9 % 1 %

58 Emergency Preparedness Eight in ten Americans believe it is extremely or very important that hospitals in their state are prepared to handle large numbers of patients after a natural disaster or terrorist attack. % indicating how important it is that trauma centers or hospitals in their state are specifically prepared to handle a large number of patients in the event of a natural disaster or terrorist attack: 79% Not sure 1% Q815 How important is it that trauma centers or hospitals in your state are specifically prepared to handle a large number of patients seriously injured due to a natural disaster or terrorist attack? Would you say it is Base: All respondents (N=1000)

59 Impact of UCSD on Trauma Care Complications List Types Hoyt, 1992 Basis for modern trauma registries Development of California Trauma System Hoyt, Coimbra, 2008 Current NTDB was born at UCSD Hoyt, 1994 International Trauma Systems Development Kuwait, Korea, Hong Kong, Colombia Research 479 papers in 25 years

60 Conclusions Trauma Systems work Political Desire Involvement of Press and Community leaders Trauma Center is just one piece Pre-hospital and Hospital should work together Trauma systems The base for the care of disasters and mass casualties.

61 Conclusion Trauma is a disease It needs attention Political Financial Research Infrastructure Prevention Trauma systems make a difference

62 The Team Faculty R. Coimbra MD, PhD B. Potenza MD J. Doucet MD V. Bansal MD J. Lee MD Leslie Kobayashi MD TPM S. Pacyna RN Basic Research Brian Eleceiri PhD Andrew Baird PhD Nicole Lopez MD Michael Krizyzaniak MD Yan Ortiz-Pomales MD International Research Fellows Luiz Guilherme Reis MD Clinical Wound Center G. Mulder DPM Prevention Linda Hill MD Kevin Patrick MD Programmer / Analyst Dale Fortlage BA Trauma Registrar P. Stout RN C. Mohrle RN Data Entry and Maintenance E. Hernandez Administrative Assistant R. Velez

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