Memorial Health University Med Center Elaine Frantz (did...

G e o r g i a C o m m i t t e e f o r T r a u m a E x c e l l e n c e

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Memorial Health University Med Center Elaine Frantz (did not sign roster)

Marie Dieter

Morgan Memorial Hospital

Northeast Georgia Medical Center Deb Battle Mary Lou Dennis Janice Labbe & Londa Greene

North Fulton Regional Hospital Jim Sargent

Phoebe Putney Memorial Hospital

Sheppard Center

Taylor Regional Hospital Carlisa Payne (on teleconference)

Trinity Hospital of Augusta Fran Swindell WellStar Kennestone Laura Garlow Portia Godboldo Wills Memorial Hospital

State Office of EMS Renee Morgan Marie Probst Danlin Luo GTCNC Jim Pettyjohn John Cannady Judy Geiger

I. Welcome and Introductions

R. Medeiros Meeting called to order at 1000 Welcoming comments by Dr Jeff Nicholas Trauma Medical Director, Grady Memorial

Hospital Introduction:

o Marie Dieter the new Trauma Program Manager at Memorial Health University Med Center in Savannah, GA. She comes to GA from PA and has extensive experience in the trauma industry

o Julie Long, New CNO at Effingham Hospital Deb Battle at Northeast Georgia Medical Center introduced Linda Greene as her second

trauma registrar and Janice Labbe as the Trauma PI & Education Coordinator. Deb also announced the promotion of Mary Lou Dennis to the position of Registry Supervisor/Clinic Practice Administrator

Quorum established by the Laura Garlow

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II. Approval of Minutes

L. Garlow September 2012 Minutes presented by Laura Garlow

o Motion to approve by Greg Pereira o Seconded by Jo Roland o Approved by Membership

III. Sub-committee Updates

R. Medeiros a. PI/Registry

L. Adkins/J. Roland

b. Education/TAG D. Kitchens

Regina Medeiros requested that each sub-committee chair send copies of their minutes to Laura Garlow for the record. These will be available on the GCTE website. DI V5 product presentation:

o There was an extensive presentation by John Kutcher from DI demonstrating the V5 product followed by much discussion and feedback to DI. Each trauma center will have the opportunity to evaluate the product on a “playground” and send evaluations to Liz Adkins and Rochella Mood. The discussion and presentation lasted for approximately 45 minutes.

This sub-committee met following the GCTE meeting in September and suggested the development of a PI matrix so all TCs are the same.

There was discussion regarding the 48-hour trauma registry inclusion criteria which is not aligned with the NTDB. This group recommends increasing inclusion to include those with LOS of 24 hours and will forward this to the Trauma Medical Director’s Sub-Committee and to Dr O’Neal. DPH and Dr O’Neal have a list of inclusion criteria they will be presenting to the PI/Registry group at their meeting later this afternoon.

TOPIC is scheduled for Nov. 30th at MCCG. Please confirm registration with Virginia Land

Current course schedule is attached. TCAR funding request was submitted with funding calculation errors resulting in a cost

over-run of more than $30,000 if we host a second course. The Sub-committee elected to cancel the second course. The first course scheduled for Dec 3 & 4th at WellStar Kennestone will be evaluated to determine if there is value in seeking funding for additional GA courses.

GAEMS/ASPR funded ATLS/ATCN course in May of 2013 is scheduled TAG Website: Courses are being added to the TAG website and each course will be

limited to a single contact person who will likely be the contact person for TAG which

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c. Specialty Care T. Walton

d. Injury Prevention E. Wright

may be a compensated position in the future. Course Directors will need to be in close contact with this individual. Please encourage use of the TAG website. There will be an interactive calendar under the “Events” tab. There will be additional tabs including Injury Prevention.

Consider additional education via video tape on the GAEMS website. Specialty Care Committee represents pediatric, rehabilitative and burn care with a focus

on completing 1 goal for each area each year. There are representatives from Grady & Still Burn Centers as well as Shephard and CHOA. The 3 Level 1’s with Peds commitment should also be participating in this group.

Pediatric o TAG has scheduled some ENPC courses throughout the state but we need more

instructors. Rehabilitation

o There was discussion surrounding the need for a model center and they are exploring the potential of designating rehabilitation centers much like the trauma center designations.

Burns o ABLS courses are on the ASPR calendar but there is a need for increasing access

to the ABLS courses across the state.

This sub-committee is seeking goals and ideas for projects. Please send these to Tracie Walton

The Sub-committee met July 12 at Shepherd. The plan to push out Concussion awareness and safety information. Falls prevention and geriatric population IP initiatives have been tabled for now.

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e. Special Projects G. Solomon

f. Resource Development L. Kubik

This group is considering ideas related to a newsletter which can be distributed electronically through TAG website. Topics can include education, awareness, IP, new trauma center highlights, coding and abstracting tips, state registry data, RTAC news, etc.

Readiness Survey: Due Nov. 30, 2012

Lauren is not able to attend today. Report provided by Laura Garlow. The sub-committee has not met since the initial meeting in September. They are working

on creating a realistic timeline for hospitals considering trauma designation as well as a current catalog of resources. We are seeking resources from other states to develop training for those who conduct designation and re-designation site visits.

IV. GTCNC Update/Contracts

E. Frantz/J. Pettyjohn

Elaine Frantz commented on Grady’s hospitality and thanked them for being out gracious hosts for today’s meeting.

Elaine highlighted portions of the most recent GCTNC meeting: o Elaine elaborated on a letter of solidarity between Dr O’Neal and Dr Ashley

seeking collaboration form all parties in advancing the trauma system in GA. She reiterated that we want to eliminate silos of practice.

o Some hospitals (both TC and non-TCs) may have been contacted by the Office of Audits and Accounts focusing on expenses of the GTCNC. The audit is due to the GTCNC in November

o The GCTNC is considering the formation of a foundation as a source of funding projects related to improving trauma care in GA. They are considering asking Greg Bishop to research this possibility and develop a framework and business plan. The GCTE membership suggested that there are already foundations and perhaps one option to reduce costs is to partner with an existing foundation for trauma care.

o GA Trauma Performance Tools are additional concepts the GTCNC is

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considering. They want to look at outcomes measures. There is consideration for all GA non-TCs to convert from ICD-9 to ISS for better comparative data collection and reporting. DPH and DI are working on a joint project but it must be cleared by the Attorney General first.

o Uncompensated Care Claims Audit Report was approved. o Exhibit 5 from GTC contracts will be replaced with the next amendment. Greg

Pereira suggested that all amendments be sent to the GTCE Executive Committee for review for input and suggestions before moving forward. It was further suggested that 5 business days be allotted for feedback before submitting changes to individual hospitals.

V. Report from State Office of

EMS & Trauma

R. Morgan/M. Probst

Renee Morgan relayed that Dr O’Neals concerns for data collection witll be reported to the PI/Registry Committee today.

The TC Designation Pre-Review Questionnaire is under review. Resource documents are under construction Any TC verified by the ACS will automatically be a state designated facility.

VI. Trauma Communications

Center Update

J. Canady

Brief reminder of the purpose of the TCC was reiterated. No new information was reported.

VII. EMS Patient Tracking System

Kelly Nadeau Ms. Nadeau presented information related to a patient tracking system which will be

implemented in GA There was discussion regarding health care preparedness in GA as well as 2 grants

related to Emergency Preparedness for Health Care Systems through ASPR/HHS and the CDC

It was strongly suggested that the biggest gap is not in planning but rather in coordinating efforts. The 5-year plan is to enhance regional coordination which were shared with the group which culminate is regional exercises which should provide feedback for improvement.

NEXT MEETING: 12/19/2012: Madison Chophouse & Grill, Madison, GA

Respectfully Submitted: Laura Garlow, RN, BSN

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Georgia Trauma Commission: EMS Subcommittee on Trauma Meeting Minutes: 03 January 2013 Page 1

EMS SUBCOMMITTEE ON TRAUMA

MEETING MINUTES

Thursday, 03 January 2013 Scheduled: 12:00 pm to 2:00 pm

Letton Auditorium Atlanta Medical Center

Atlanta, GA

CALL TO ORDER Mr. Ben Hinson called the January meeting of the EMS Subcommittee on Trauma to order at Letton Auditorium located in the Health Services Building of the Atlanta Medical Center in Atlanta, GA at 12:08 PM

SUBCOMMITTEE MEMBERS PRESENT SUBCOMMITTEE MEMBERS ABSENT Ben Hinson, Chair Subcommittee & GA Trauma Commission Member Pete Quinones- Region Three Lee Oliver – Region Five Blake Thompson – Region Six Huey Atkins – Region Ten Courtney Terwilliger - EMSAC Linda Cole – GA Trauma Commission Keith Wages - OEMS

Jimmy Carver – Region Seven Craig Grace – Region Eight/Excused Dr. Leon Haley-GA Trauma Commission/Excused Randy Pierson – Region One/Excused Chad Black – Region Two/Excused Richard E. Lee – Region Four David Moore – Region Nine

OTHERS SIGNING IN REPRESENTING Jim Pettyjohn John Cannady Judy Geiger Dr. Jill Mabley Kim Littleton Kristal Smith Lanier Suuttuel Jason Troupe

Georgia Trauma Commission Georgia Trauma Commission Georgia Trauma Commission OEMS/T GAEMS Region 5 RTAC Dawson County Emergency Services Southern Regional EMS

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Welcome and Introductions Mr. Ben Hinson welcomed all who were present and thanked everyone for coming. Approval of Minutes from July Meeting The first order of business was the approval of the minutes from the October 2012 subcommittee meeting. MOTION #1 EMS Subcommittee 2013-01-03:

I make the motion to approve the minutes from the July 2012 meeting as written.

MOTION BY: BEN HINSON SECOND: COURTNEY TERWILLIGER ACTION: The motion PASSED with no objections, nor

abstentions.

GEORGIA TRAUMA COMMUNICATIONS CENTER UPDATE Mr. John Cannady reported for the Trauma Communications Center, indicating that with the end of the first full year of operations the TCC has received a total of 717 calls. Comparatively, this number is higher than other states were during their first year, such as Alabama and Arkansas. Of the 717 patients, 648 met TSEC criteria; this number has shown an increase over the course of the year. Mr. Ben Hinson inquired as to the breakdown of hospital to hospital transfers, to which Mr. Cannady replied that this number was still low, at approximately 29 calls. He further indicated that improving this number was a goal of the TCC and strategies were being introduced to make these differences. Discussion followed regarding the struggles with hospital transfers, current relationships, and how the TCC can help. Mr. Cannady indicated that a questionnaire was being created for the hospitals to allow insight into the answers to these questions, and Mr. Hinson requested that this Subcommittee be allowed to review the questionnaire before distributing, and also share with the Trauma Commission to gain better insight. Mr. Cannady agreed. Mr. Hinson inquired as to how many of the 648 patients which met trauma criteria were taken to trauma centers, to which Mr. Cannady replied that there were 607. Discussion followed regarding the outcome for the trauma patients who were not taken to designated trauma centers and the reasons that those trauma patients were taken to hospitals that were not designated trauma centers. Medic discretion was cited as the main reason for a trauma patient to be taken to a nearby non-designated hospital, however further research will be necessary for indicating the outcomes for those patients as many are taken to hospitals which are not participating. Mr. Cannady continued his report indicating that the TCC Advisory Board will now be effective as a Subcommittee of the Commission and will be known as the TCC Subcommittee; the first meeting has not yet been scheduled but will likely take place around the time of the Trauma Commission Workshop at the end of this month.

Brandon Fletcher P. Prince

Southern Regional EMS SOEMS

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Further upcoming changes in the technology include an EMS user screen included on the Resources Availability Display (RAD). This will provide access to EMS to view the RAD as well as create patient records; thus allowing the TCC to access this information. Discussion ensued regarding whether this would be best used in the vehicle or the dispatch center, which would be the decision of the individual agencies. Other technology considerations include the AVLS basic communications systems, and the Georgia Interoperability Network (GIN). FY 2013 EMS GRANTS UPDATE Mr. Jim Pettyjohn provided the report indicating that grant funding has been opened and closed for both the EMS Uncompensated Care Grant and EMS Vehicle Replacement Grant. Forty agencies submitted claims; each claim goes through an audit process to ensure that they have met criteria. Ms. Judy Geiger continued the report demonstrating the timeline for the process, explaining how the claims for audits will be chosen and providing an explanation of the scheduled testing. Mr. Pettyjohn advised that there were 41 applications received for ambulance grants. This year, for both the EMS Uncompensated Care program as well as the EMS Vehicle Replacement Grant, a condition for receiving the award compliance with the state data download is required; OEMS/T has been asked to validate this compliance. FUTURE EMS FUNDING DISCUSSION Mr. Courtney Terwilliger provided a handout (See attached), and explained that this handout outlines the FY 2011 and FY 2012 Grant Funding process. There have been 19 First Responder courses and one First Responder Instructor course provided. Mr. Terwilliger explained the document, stating that there were 19 grants awarded, ten of which were completed and nine that were not. Of the 198 students who began the course, 170 completed with an 85.9% completion rate. In meeting with some of the instructors across the state, Mr. Terwilliger suggested that it would be more cost effective to have a level 2 instructor course rather than a first responder instructor course, as this would allow the teaching of multiple areas of subject. GPSTC has agreed to have to applications available for this course. This class will last approximately five or six days and be located at the Georgia Public Safety Training Center, with rooms available for overnight stay. Discussion followed regarding the goals and problems of the instructor courses, as well as the difficulty and benefits of the course. Mr. Terwilliger continued his report, explaining that the handout includes several spreadsheets; the first describes the First Responder Grant Funding for FY 2012, which currently has two classes that have already begun. The grant criteria used is the same as was previously used, with the exception of some wording that had received a request for changes from the Trauma Commission. Mr. Terwilliger further explained the benefit of cross training EMS personnel and Fire personnel, as they will be able to better assist one another on scene. Instructors who have the ability to teach both of these classes will be beneficial, and work is being done to possibly change this curriculum. The Trauma Equipment Grant Program has awarded funds for the applications which were received and validated. The EMS Directors who received the grant funds were notified that the funds were to be used for trauma equipment and an avadavat is required for verification. The last two pages is an Invoice Addendum which is used for the OEMS/T and describes the requirements for course curriculum. OLD BUSINESS Mr. Ben Hinson provided an update regarding the Data Subcommittee which has been reappointed. The Georgia Hospital Association has gathered discharge data from hospitals which previously have been unavailable. With the assistance of OEMS/T and the Georgia Hospital Association, some of this data is

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now available for the Trauma Commission to review. This information however does not include the trauma severity code, or injury severity score. An algorithm has been built that looks at the ICD9 score, and other data and projects what the injury severity score would have been. This is then compared this to the trauma registry score to validate the process. If this proves to be accurate it will provide a way to show where patients were taken, and a way to prepare community hospitals, teaching hospitals, and trauma centers and will assist hospitals with training as well as provide a source of information. Georgia is the first state to do this statewide. NEW BUSINESS Mr. Courtney Terwilliger addressed the subcommittee regarding First Responder Classes, requesting that a limit be placed on the number of grants awarded to an individual agency over a period of years. Mr. Terwilliger explained a county or agency that meets qualifications one year, will continue to meet those qualifications each year following. Furthermore, Mr. Terwilliger suggested that purchased books be kept and reused to economize the budget, and allow training to more people. Discussion ensued regarding how this work including the possibility of using a point system for determining grants, and how and where books could be stored. Mr. Terwilliger further recommended adding a condition to equipment grants which would ensure that certain items be given priority for purchase before any other equipment. Mr. Terwilliger provided the example of IV fluids, stating that ambulances are cold and IV fluids need to be kept a particular temperature. The question was presented that if IV fluid warmers were required on the trucks before other equipment could be purchased this would help resolve this matter. Discussion followed regarding whether or not there was any other equipment that should be required, as well as the possibility that requiring items in this matter may cause an agency to not be able to purchase an item that they are more in need of. Further discussion explored the possibility of a survey to help answer these questions, and the type of questions that should be asked. Mr. Terwilliger advised that he would work toward putting together this questionnaire, and suggested involving the Medical Directors to provide input. NEXT MEETING DATE AND ADJOURN Mr. Hinson reminded the subcommittee that date of the next meeting will be pending approval of the Trauma Commission meeting schedule, as the EMS Subcommittee on Trauma will meet on the first Thursday of every month that the Trauma Commission meets. Pending approval, the next meeting will take place on March 7th in Macon. Notification of the final decision will be provided. Meeting adjourned at 1:07 PM. Crafted by Tammy Smith

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Data Subcommittee Conference Call: 05 December 2012 Attending: Dr. Dennis Ashley Ms. Lauren Noethen Mr. Jim Pettyjohn Mr. John Cannady Dr. Danlin Luo Ms. Renee Morgan Ms. Marie Probst Mr. Keith Wages Mr. Greg Bishop Ms. Liz Atkins Ms. Linda Cole Dr. Pat O’Neal Mr. Ben Hinson, Chair Ms. Elaine Frantz Dr. Danielle Tack Meeting Notes: Meeting Began: 2:08 PM Mr. Hinson welcomed everyone and thanked them for participating. Mr. Hinson briefly explained to the subcommittee the background of the Data Subcommittee, explaining that this was a newly reformed subcommittee that originated approximately five years ago. He explained that with so much data available it became overwhelming to analyze, this committee has now been reformed to accomplish this task. Mr. Hinson continued by discussing the importance of the work, and the type of data that will be looked at. He advised that the subcommittee should be careful as to how the data is gathered and analyzed so as to avoid misconceptions. Mr. Hinson requested for Mr. Greg Bishop to provide a report explaining his project. Mr. Bishop reported regarding the Hospital Discharge Data Summary handout which was distributed via email (attached to these notes). He explained that this report shows the level of patients who are being treated in trauma centers in Georgia during 2006 based on ISS scores, and compares to scores from 2011. He continued by explaining how this software is in need of updating for more accurate estimates of ISS scores for patients in Georgia. The problem with the data is that it was done in 2006 based on 1996 ISS scoring using diagnosis codes in the hospital data set for the entire state. The injury scoring algorithm changed, but the software was never updated. Data set is handled by Digital Innovations, and currently in process of being updated.

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Mr. Bishop continued by explaining the data sets that have been done in the past, and what is being done currently by comparison, as well as where things should continue for future data sets. Discussion followed regarding how the ISS scores are used, the difference between hospital level and severity of injury, as well as the consistency of the data gathered. Algorithms from 2006 will be run against the data to compare the scores against the ISS scores provided by the trauma centers to verify validity. Mr. Bishop clarified for the group the decisions which need to collaborate:

1. Identify how the patients will be identified; this will need to be consistent every time the data is analyzed.

2. Once this is decided, the data will then be given to someone within the trauma centers to have their registry people compare it and see: A. Are we getting the right ISS scores? B. Are we getting the right patients?

Discussion followed regarding the involvement of other agencies, as well as how the data will be collected and what data would be looked at such as centralized data; age, length of stay, characteristics, and how long the analysis would take. Further discussion ensued regarding how the patients would be identified and how to narrow down the information, indicating that characteristics could be the identifiers and that this would be best handled at the hospital level. Mr. Hinson requested that Mr. Bishop provide for Dr. O’Neal and Mr. Pettyjohn, and himself on what is being done; send this to the hospitals and get started and see how things match up. Mr. Bishop suggested that Dr. Ashley’s hospital (MCCG), Ms. Frantz’s hospital (Memorial) and Ms. Atkins’ (CHOA) participate. Further suggestions included having assistance in determining the definition used before for identifying trauma patients from the hospital discharge data. Mr. Hinson inquired of the subcommittee whether or not the group would prefer that Mr. Bishop report back regarding their findings our make a decision and move forward. Mr. Bishop responded that reporting back with to the subcommittee with the algorithms would be preferential, and Mr. Hinson indicated another call will be arranged when the data is ready for further discussion. Mr. Hinson indicated that part of this subcommittee’s responsibilities will be to find data to support some of the assumptions that the Trauma Commissions is working with and find data to support these going forward. For example looking at some of the CDC data as well as the numbers for trauma in Georgia compared to other states and check for accuracy. Notification of next meeting will be sent by email. Meeting adjourned 3:00 PM

Meeting Notes Crafted By Tammy Smith

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Hospital Name ISS 0-8

ISS 9-14

ISS 15-24

ISS 24+

ISS Total

ISS 15+

Total 1A 590 694 652 333 2,269 985 1B 212 367 366 155 1,100 521 1C 373 361 286 149 1,169 435 1D 272 423 314 100 1,109 414

Level I Subtotal 1,447 1,845 1,618 737 5,647 2,355 Level I% 26% 33% 29% 13% 100% 42%

2A 325 436 365 148 1,274 513 2B 172 308 223 79 782 302 2C 204 324 204 91 823 295 2D 119 246 155 57 577 212 2E 82 111 84 29 306 113 2F 82 112 96 10 300 106 2G 80 75 33 4 192 37 2H 147 118 112 45 422 157 2I 128 105 95 39 367 134

Level II Subtotal 1,339 1,835 1,367 502 5,043 1,869 Level II% 27% 36% 27% 10% 100% 37% Level I & II Subtotal 2,786 3,680 2,985 1,239 10,690 4,224 Level I & II% 40% 44% 62% 81% 49% 67% Other Hospitals 4,191 4,695 1,815 287 10,988 2,102 Other Hospitals % 60% 56% 38% 19% 51% 33% Total GA Volume 6,977 8,375 4,800 1,526 21,678 6,326 GA % by ISS Category 32% 39% 22% 7% 100% 29% Mature System Norm Percentages 50% 65% 80% 90% N/A N/A # of Mature System Norms 3,489 5,444 3,840 1,373 14,146 65% % of trauma patients in GA treated at TC’s 40% 44% 62% 81% 49% 67% % of trauma patients in GA not treated at TC’s 60% 56% 38% 19% 51% 33% # of trauma patients in GA not treated at TC’s 4,186 4,690 1,824 290 10,990 51%

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GEORGIA TRAUMA SYSTEM PERFORMANCE TOOL Concept & Development

August 2012 CONCEPT Statewide hospital discharge data sets (SHDDS)i, due to steadily improving data coverage and quality, are increasingly valuable in healthcare data analysis.ii In combination with a new software algorithm iii that assigns reliable injury severity scores (ISS) based upon ICD-9 diagnosis codes, the SHDDS promises to be a powerful, cost-effective tool for assessing state trauma system performance. The Georgia Trauma System is positioned to be the first that employs this new technology in measuring its performance. While trauma centers contribute to detailed statewide trauma registries, other hospitals do not. A major priority of trauma system development nationally has been to obtain data on the injury patients they treat (and who do not reach trauma centers) to enable assessments of trauma system performance. The strategy was to turn all hospitals into at least a Level IV trauma center, obligating them to provide data. This strategy has had little success. Statewide Hospital Discharge Data Elements When coupled with an ISS score, SHDDS provide an alternative in that they include basic data on every patient admitted to each hospital in each state:

• Treating hospital • ICD-9 diagnosis codes • Mechanism of injury (E code) • Procedure codes • Length of stay • Age, sex

Adding an ISS score enables severity-based analysis of the state’s injury patients, including (in combination with E codes and other data) the identification of injury patients meeting trauma center triage criteria. Use In Georgia Trauma System Assessment This will enable the GTCNC, in collaboration with OEMS/T, Georgia’s RTACS and other stake-holders, to determine the volume and severity of trauma patients being treated at non-trauma hospitals. Additional applications of this data set include: • Assessment of subset injury populations such as pediatric and burn patients • Determining the impact of new trauma centers on existing centers and other hospitals • Economic profiling of a potential new trauma center to determine potential viability • Evaluation of ISS scoring by trauma centers (by comparison to an ISS algorithm norm) • Other uses defined in project

A comparison of care quality in trauma centers vs. non-trauma centers in terms of complications and preventable deaths, using the abbreviated injury score (AIS)iv used to calculate the ISS, is also possible. The ISS scored data set also can be provided to OEMS/T to support endeavors in trauma epidemiology in a collaborative effort that perhaps includes linking the data with the statewide trauma registry.

• Payer class • Charges • Type of admission • Patient source (ED, transfers) • Patient disposition • Zip code of residence/County

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DEVELOPMENT Bishop+Associates (B+A) has used SHDDS extensively for two decades in projects with trauma centers and systems. B+A has worked with Digital Solutions (DI), a pioneer in the development of trauma registries and data systems, to make an updated ISS scoring tool available for SHDDS. DI re-engineered a state-of-the-art trauma registry software component that uses AIS 2005 (update 2008) to calculate ISS scores for this purpose. B+A and DI have initially tested this tool for validity on one state’s SHDDS where B+A had actual ISS data from trauma centers for comparison. The resulting ISS scoring closely matched the volume and severity of actual trauma centers; definitive validity testing would be conducted in Georgia as part of this project. Development in Georgia will be conducted as a research project to assure a high level of credibility in the results and enable appropriate reporting at the national level. B+A has also developed an extensive algorithm for identifying likely trauma center candidate patients within a SHDDS, using the following factors:

• Treating hospital/trauma center • ICD-9 diagnosis codes • Mechanism of injury (E code) • Injury severity score • Age • Type of admission • Patient source (ED, transfers) • Length of stay

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This project will contribute to the development of a software tool for assessing a SHHDS that can be distributed to individual trauma systems and researchers for ongoing use. This approach to assessing trauma system performance will be strengthened once the more robust ICD-10 diagnosis codes are implemented. I . DEVELOP GEORGIA TRAUMA SYSTEM PERFORMANCE TOOL

A. Form Project Task Force

This task force will be composed of representatives of the GTCNC, OEMS/T and the RTACS, will be Chaired by Dennis Ashley, MD and supported by B+A.

1. A key function of this task force will be to define specific objectives for this analysis to

ensure various needs are taken into consideration.

2. This group will also serve as a sounding board for collaborative initiatives such as linking SHDSS and trauma/burn registry data.

B. Calculate An ISS Score For Georgia Statewide Hospital Discharge Data Set

The most recent year of Georgia's statewide hospital discharge data will be obtained from the Georgia Hospital Association and assessed for data elements it incorporates. B+A/DI will process this SHDDS to add an ISS to each injury patient.

C. Identify Likely Trauma Center Patients In The Georgia SHDDS B+A will use its algorithm for identifying likely trauma center candidate patients on the Georgia SHDDS. As a second step, the results of both the ISS assignment and trauma patient identification will be compared with actual data from several Georgia trauma centers to test validity.

D. Provide OEMS/T With Scored data set B+ A will provide OEMS/T the full Georgia SHDDS with the ISS assignment and the indicator of whether an injury patient is a trauma center candidate patient, and the benefit of B+A's experience in working with this unique data set. This will ensure the full the use of SHDDS data improving trauma care in Georgia. Support for OEMS/T linking SHDDS data with Georgia trauma registry data can also be given.

E. Review Results With Project Task Force Preliminary results of the Georgia trauma system performance assessment will be shared with the Project Task Force. The analysis will be updated as needed, and feedback on the actual results will be requested.

F. Produce Georgia Trauma System Performance Assessment Based upon the objectives defined by project task force, B+ A will prepare a concise report covering all aspects of the Georgia trauma system performance assessment. 1. B+A will assist the leadership of the project task force in writing up this project and its

results in a manner that can be submitted for publication.

2. B+A will also support the Project Task Force in its presentation of this assessment to the GTCNC.

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Timeframe 120 days. B+A Qualifications BA developed this approach based upon unique and extensive experience with SHDDS. DI has the largest installed trauma registry base in the nation, and the most sophisticated rules engine for determining an ISS score from ICD-9 codes based upon 2005 AIS update 2008. B+A Project Costs Project cost is $22,500. i Federal regulations require acute care hospitals to submit selected data on all patients, which is compiled at the state level. In Georgia the Georgia Hospital Association administers the statewide hospital discharge data set. ii The Value of Hospital Discharge Databases, National Association of Health Data Organizations, May 2005.

iii ICDMAP is the name of an ISS scoring algorithm, last updated in 1995, that was developed at John Hopkins. In 2004, the Expert Group on Injury Severity Measurement of the National Center for Health Statistics recommended ICD/MAP be maintained and updated.iii This never happened but a new scoring mechanism updated based upon AIS 2005 (Update 2008) is now possible due to collaboration between Digital Solutions, Inc. and Bishop+Associates. iv The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in 1969. It essentially ranks all injuries in terms of severity, and since that time it has been revised and updated against actual survival. The latest version is AIS 2005 (Update 2008). Federal regulations require acute care hospitals to submit selected data on all patients, which is compiled at the state level. In Georgia the Georgia Hospital Association administers the statewide hospital discharge data set. iv The Value of Hospital Discharge Databases, National Association of Health Data Organizations, May 2005. iv ICDMAP is the name of an ISS scoring algorithm, last updated in 1995, that was developed at John Hopkins. In 2004, the Expert Group on Injury Severity Measurement of the National Center for Health Statistics recommended ICD/MAP be maintained and updated.iv This never happened but a new scoring mechanism updated based upon AIS 2005 (Update 2008) is now possible due to collaboration between Digital Solutions, Inc. and Bishop+Associates. iv The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in 1969. It essentially ranks all injuries in terms of severity, and since that time it has been revised and updated against actual survival. The latest version is AIS 2005 (Update 2008).

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Georgia Trauma Commission: Data Subcommittee Meeting Notes: 09 January 2013 Page 1

Data Subcommittee Conference Call: 09 January 2013 Attending: Mr. Ben Hinson, Chair Ms. Lauren Noethen Mr. Jim Pettyjohn Dr. Danlin Luo Ms. Rana Bayakly Ms. Renee Morgan Ms. Marie Probst Mr. Keith Wages Mr. Greg Bishop Ms. Liz Atkins Ms. Linda Cole Dr. Pat O’Neal Ms. Elaine Frantz Dr. Danielle Tack Meeting Notes: Meeting Began: 1:01 PM Mr. Ben Hinson welcomed everyone and thanked them for participating. Mr. Greg Bishop was asked for an update. Mr. Bishop reported that he with the assistance of Ms. Rana Bayakly was tasked with the responsibility of selecting the rules for selecting trauma patients from the larger data set. To do this, the total data set for MCCG was sent to the hospital for analysis and also for the purpose of confirming the accuracy of the data. Numbers were then compared to the trauma registry to ensure accuracy. There were some issues in attempting to match up patients with the information available. Mr. Bishop explained that there were details that would assist this process, such as discharge dates, length of stay and age. Mr. Bishop explained that with the data having been first sent to MCCG, then to GHI, DI, and back; each processing it for the purpose of matching up data with medical records for the determination of confirmation of accuracy. Mr. Bishop noted that another issue that arose was in regards to trauma issued scores for ISS and ICD9 Scores, as they may be different than what had been identified by medical records. Furthermore, there is a question to the effectiveness of the coding process. Each step is to ensure the integrity of the process. Mr. Bishop continued by discussing the selection process, the difficulties, and the reasons that the process is taking slightly longer than originally anticipated. Discussion ensued regarding how patients were chosen or eliminated for the purpose of this data, such as the elimination of those patients who have been discharged within the first 48 hours (Noting that for data beginning 2013, this will be considered at 23 hours and 59 minutes). Further discussion considered a similar study which took place in Florida, and the methods that were used for their study by comparison.

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(http://www.acssurgerynews.com/specialty-focus/traumacritical-care/singleview-enewsletter/florida-s-trauma-program-succeeds-at-patient-triage.html) Further discussion followed regarding how the numbers would be affected if the patient was first taken to a non-designated hospital before being taken to a trauma center, as well as the expectancy for validation. Mr. Jim Pettyjohn explained that with the trauma registry coding being conducted more efficiently it may be expected that those scores based on hospital discharge data may be less than the trauma registry for the same patient. Mr. Bishop agreed, and added that a pattern should be produced. Ms. Rana Bayakly inquired as to the process, and confirmed that the numbers were not matching up. Mr. Bishop agreed and explained that the patients were not matching up and it was too soon to attempt to make any conclusions. Discussion followed regarding what the next steps should be; Mr. Bishop advised that the process required further details such as discharge dates, age, length of stay and the IC9 and E-Codes. There is a possibility of data corruption, but it is too early to indicate at this time. Dr. Pat O’Neil ascertained whether or not elderly patients would be excluded if possible, looking at ISS Scores based on those patients who are under 65 years of age. Mr. Bishop replied that with the Florida study one of the key conclusions of the risks identified, 93% of children went to trauma centers, 85% of adults and 41% of elderly. The Florida study clearly identified the criteria for patients that were excluded from the data set. Inquiries are being made with Florida to determine if their process and findings can be of help for this study. Ms. Liz Atkins inquired regarding the Florida study; the article states their definition and references the use of ICD9 ISS of less than .85, the ability to be able to compare would be beneficial to determine how this was converted. Mr. Bishop agreed and advised that he also had this question, and added that he would have a report at the Trauma Commission meeting; however the results would not be available at that time. An update will be provided during the Trauma Commission Workshop which is scheduled for Friday, January 25, 2013. Meeting adjourned 1:23 PM

Meeting Notes Crafted By Tammy Smith

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Florida's trauma program succeeds at patient triage

By: MITCHEL L. ZOLER, IMNG Medical News 12/27/12

AT THE ANNUAL MEETING OF THE SOUTHERN SURGICAL ASSOCIATION

VITALS Major Finding: Among Florida’s severely injured patients in 2010, 93% of children, 85% of adults, and 41% of elderly went to trauma centers. Data Source: Florida’s Agency for Health Care Administration data on injured patients discharged from hospitals during 1996-2010. Disclosures: Dr. Ciesla said that he and Dr. Tepas and their associates had no disclosures. Dr. Rotondo had no disclosures. PALM BEACH, FLA. – Florida’s statewide trauma triage system, one of America’s oldest and best organized state systems, did an increasingly better job over time from 1996 through 2010 funneling severely injured children and adults to one the state’s 22 designated trauma centers, according to data collected by the state government. Florida’s program has had less clear-cut success triaging the elderly population with severe, acute trauma injuries to designated trauma centers, but the raw data may be misleading, Dr. David J. Ciesla, FACS, said at the annual meeting of the Southern Surgical Association.

David J. Ciesla

Data collected by Florida’s Agency for Health Care Administration showed that during 2010, 41% of severely injured patients older than 65 years were discharged from a designated trauma center (DTC), compared with an 85% rate among adults 16-65 years old, and a 93% rate among children under age 16, said Dr. Ciesla, medical director of the Regional Trauma Program at Tampa General Hospital. But the strikingly lower rate of elderly patient referral to a DTC may be an artifact of how Dr. Ciesla and his associates defined severe injury in their analysis. Their definition relied on survival. Using the ICD-9 Injury Severity Score (ICISS) to rate a patient’s need for DTC referral, they rated patients with ICISS of less than 0.85 (a less than 85% survival rate) as severely injured and candidates for DTC triage. But this criterion starts to break down for older patients, he explained.

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"We defined injury severity as the risk of death, but that can be age related as well as injury related. It could be that older patients are more elderly than they are injured," he said. Many of the elderly patients who were hospitalized for trauma "may be injured, but were they severely injured, or did they have high mortality because of their age or their comorbidities?" Dr. Ciesla said in an interview. "I think the Florida system works well. We have shown [in these data] that the system can identify severely injured children and adults and get them to designated trauma centers. The elderly patients we’re calling ‘severely injured’ may just be elderly who can be appropriately treated in community hospitals," he said.

Michael F. Rotondo

This interpretation received support from several surgeons who heard the talk at the meeting. "Children and adults went to designated trauma centers, while elderly patients went to the closest hospital regardless of the DTC designation. The Florida trauma system has extensive coverage for nearly all the state’s population, and adding centers will not likely improve access to trauma care but is likely to decrease performance by diluting patient volumes at the existing designated trauma centers," commented Dr. Michael F. Rotondo, FACS, professor and chairman of surgery at East Carolina University in Greenville, N.C. "Does Florida have enough trauma centers? These data basically say yes, we have enough," said Dr. Joseph J. Tepas III, FACS, professor and chief of pediatric surgery at the University of Florida in Jacksonville and a coauthor of the study. "Ninety percent of the patients were direct transfers" to a DTC, indicating that "paramedic triage discretion seems to work quite well" in routing injured patients to the appropriate hospital, he said. The study run by Dr. Ciesla, Dr. Tepas, and their associates reviewed all patients discharged from Florida hospitals during 1996-2010 using data collected by the state agency. The researchers identified injured patients by their diagnostic codes, and analyzed them by their discharge hospital and by their home zip codes. The analysis showed that the percent of severely injured patients discharged from a DTC rose from fewer than half of the state’s patients in this category in 1996 to 63% in 2010. Among 225 severely injured children, 210 (93%) were discharged from a DTC, with only 15 children who did not receive DTC treatment. The 2010 database also included 7,469 severely injured adults, with 85% discharged from a DTC, and 7,825 elderly patients, with 41% discharged from a DTC. The analysis of DTC discharges of severely injured patients by their home zip codes identified an area of the Florida panhandle, near Panama City, where several adult patients failed to receive care at a DTC, suggesting that residents in this area of the state might be better served by opening another, nearby DTC, said Dr. Ciesla, who is also director of acute care surgery at the University of South Florida in Tampa.

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"You need enough centers to cover everyone geographically, but not so many that you dilute" patient volume at individual centers, he said. The researchers have not yet analyzed the best DTC volume to produce optimal patient outcomes, he added. Dr. Ciesla said that he and Dr. Tepas and their associates had no disclosures. Dr. Rotondo had no disclosures.

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