San Diego County Trauma System Assessment Study by...

SA N D IEGO COUNTY TRAUMA SYSTEM ASSESSMEN T

San Diego CountyTrauma System AssessmentStudy

February 28, 2003

Prepared for:County of San Diego

Prepared by:The Abaris Group

i

Acknowledgments

The Abaris Group expresses thanks to the individuals who participated in theinterview process and provided background for this report. They are to be congratu-lated for their time, energy and enthusiastic participation. This valuable contributionwas beneficial to creating this report and should be of value to the future success ofthe San Diego County Trauma System.

We would like to acknowledge the following people for their direct and intenseinvolvement in this study: Kevin Anderson; John Armstrong; Kathi Ayers, RN, MSN,CFNP; Gerald Bracht; Lana Brown, RN; Mike Casinelli; Andrew Cliff; Louis Coffman;Kim Colonnelli, RN, MA; LeAnne Cooney; Gail F. Cooper; Sue Cox, RN, MS, CEN;David DeBeck; Jim Dunford, MD; A Brent Eastman, MD, FACS; Walter F Ekard; SeanEvans, MD; Sonja Fulton; Gary Fybel; Tom Gammiere; Karilyn Greenwood; BobHemker; Robert Hogan; Peggy Hollingsworth-Fridlund, RN; David Hoyt, MD,FACS; Beth Jarosz; Gwen Jones; Sumiyo Kastelic; Dot Kelley, RN, MSN, CEN; FrankKennedy, MD, FACS; Nevea Ledesma; Barry LoSasso, MD, FACS, FAAP; LawrenceMarshall, MD; Patti Murrin, RN, MPH; Beverly Neal, RN; Lisa Otte; Blair Sadler;Fred Simon, Jr, MD; Beth Sise, JD, RN, MSN, CPNP, Michael Sise, MD, FACS; AlanSmith, MPH; Kevin Thompson; Leslie Upledger Ray, MA, MPPA; Thomas Velky, MD;Gary Vilke, MD; Cheryl Wooten, RN, MSN, CNRN; Kay Young.

This report was prepared by The Abaris Group, Walnut Creek, CA.

The Abaris Group700 Ygnacio Valley Road, Suite 270Walnut Creek, CA 94596Tel: 888.367.0911Fax: 925.946.0911abarisgroup.com

SA N D IEGO COUNTY TRAUMA SYSTEM ASSESSMEN Tii

San Diego CountyTrauma System Assessment Study

Table of ContentsExecutive Summary ................................................................................................................... 1I. Overview ............................................................................................................................... 3 Purpose ................................................................................................................................ 3 Methods ............................................................................................................................... 3 Trauma System Development ............................................................................................. 4II. Inventory of Resources ...................................................................................................... 12 Overview ............................................................................................................................. 12 Prehospital Care ................................................................................................................. 12 Trauma Centers .................................................................................................................. 17 Emergency Departments ................................................................................................... 18 System Leadership ............................................................................................................. 19 Other System Components ............................................................................................... 20 Study of Best Practices ....................................................................................................... 21III.Special Topics ..................................................................................................................... 25 Trauma Triage ..................................................................................................................... 25 Trauma Registry ................................................................................................................. 34 Injury Prevention ................................................................................................................ 40 Trauma System Quality Improvement .............................................................................. 47IV. Data Analysis ...................................................................................................................... 52 Overview ............................................................................................................................. 52 Trauma Patient Demographic Profile ................................................................................ 52 Trauma Center Descriptive and Financial Data ................................................................ 65 San Diego County Trauma Volume Projections ................................................................ 70 Trauma Center Financial Projections ................................................................................ 74 Additional San Diego County Trauma Maps .................................................................... 76 Population-Based Trauma Study ....................................................................................... 87 Trauma Center Funding Comparison Study...................................................................... 89V. Conclusions and Recommendations ................................................................................ 93 Acute Trauma Care ............................................................................................................. 93 Trauma Quality Improvement ........................................................................................... 94 Trauma Triage ..................................................................................................................... 96 Trauma Prevention ............................................................................................................. 97 Trauma Registry ................................................................................................................. 98 Prehospital ......................................................................................................................... 99 Trauma Center Configuration .......................................................................................... 100 Leadership ........................................................................................................................ 102 Fiscal Planning ................................................................................................................. 104VI. Appendices ...................................................................................................................... 105 Appendix A: Study Participants ....................................................................................... 106 Appendix B: The Abaris Group Team .............................................................................. 111 Appendix C: Definitions ................................................................................................... 114 Appendix D: Best Practice Survey Summary Chart ......................................................... 117 Appendix E: CA Comparison of Trauma Triage Criteria .................................................. 122

SA N D IEGO COUNTY TRAUMA SYSTEM ASSESSMEN Tiii

List of Exhibits

Exhibit 1 - United States Trauma Centers ..................................................................................6Exhibit 2 - Rates of Suboptimal Care and Preventable Death....................................................8Exhibit 3 - San Diego Trauma Centers ........................................................................................9Exhibit 4 - Trauma Center Admissions by Fiscal Year .............................................................. 10Exhibit 5 - California County Trauma System Comparison...................................................... 11Exhibit 6 - San Diego County Transporting Agencies .............................................................. 12Exhibit 7 - San Diego County Base Hospitals .......................................................................... 13Exhibit 8 - San Diego County Committees ............................................................................... 15Exhibit 9 - San Diego County ED/Trauma Diversion Hours .................................................... 16Exhibit 10 - San Diego County Average Monthly Diversion Hours ......................................... 16Exhibit 11 - San Diego County Rehabilitation Facilities ........................................................... 20Exhibit 12 - Best Practice Survey ............................................................................................... 24Exhibit 13 - Comparison of Trauma Registries ......................................................................... 38Exhibit 14 - MAC Committee Membership .............................................................................. 48Exhibit 15 - Pre-MAC Review Team Membership .................................................................... 48Exhibit 16 - San Diego County Trauma by Age ......................................................................... 52Exhibit 17 - San Diego Trauma by Sex ...................................................................................... 52Exhibit 18 - San Diego Trauma by Race Ethnicity .................................................................... 53Exhibit 19 - Most Frequent Diagnoses of Trauma Patients ..................................................... 53Exhibit 20 - Most Frequent Procedures for Trauma Patients ................................................... 54Exhibit 21 - Trauma Patients by ISS Distribution ..................................................................... 54Exhibit 22 - Trauma Volume by SRA ......................................................................................... 55Exhibit 23 - Trauma Utilization Rate per 1,000 People by SRA ................................................ 56Exhibit 24 - Causes of Traumatic Injury .................................................................................... 57Exhibit 25 - Motor Vehicle Crashes by SRA .............................................................................. 57Exhibit 26 - Trauma by Intent of Injury ..................................................................................... 58Exhibit 27 - Trauma by Day of the Week ................................................................................... 58Exhibit 28 - Trauma by Hour of the Day ................................................................................... 59Exhibit 29 - Response Time to Trauma Scene .......................................................................... 59Exhibit 30 - Average Ground Ambulance Response Time by SRA .......................................... 60Exhibit 31 - Transport Time for Trauma Patients ..................................................................... 61Exhibit 32 - Average Ground Ambulance Transport Time by SRA .......................................... 62Exhibit 33 - Traffic "Hot Spots" in San Diego .......................................................................... 63Exhibit 34 - Average Length of Stay .......................................................................................... 64Exhibit 35 - Trauma Patient Definitions ................................................................................... 65Exhibit 36 - Hospital Data ......................................................................................................... 67Exhibit 37 - Emergency Department Data ................................................................................ 68Exhibit 38 - Trauma Department Data ..................................................................................... 69Exhibit 39 - San Diego County Trauma Volume Projections ................................................... 71Exhibit 40 - San Diego County Actual & Projected Trauma Volume ....................................... 72Exhibit 41 - San Diego County Actual & Projected Trauma Volume by Trauma Center ......... 72Exhibit 42 - Trauma Center Financial Projections .................................................................... 76Exhibit 43 - Location of Trauma Centers and Major Roadways ............................................... 77Exhibit 44 - The Number of Trauma Cases by SRA .................................................................. 78Exhibit 45 - Trauma Center EMS Transport Volume ................................................................ 78Exhibit 46 - Population Density by SRA .................................................................................. 798Exhibit 47 - Projected Population Growth by SRA for 2000 to 2010 ........................................ 80

SA N D IEGO COUNTY TRAUMA SYSTEM ASSESSMEN Tiv

Exhibit 48 - Trauma Rate per Square Mile by SRA ................................................................... 81Exhibit 49 - Pediatric Trauma Volume (Aged 0 - 14) by SRA ................................................... 82Exhibit 50 - 3-D Illustration of Trauma Volume SRA With Catchment Areas .......................... 83Exhibit 51 - Proposed Trauma Catchment Areas by San Diego City Fire Department ........... 84Exhibit 52 - Effect of One Trauma Center Leaving the San Diego County Trauma System .... 85Exhibit 53 - Effect of Two Trauma Centers Leaving the San Diego County Trauma System ..86Exhibit 54 - Distribution of Trauma Among Hospitals ............................................................ 88

SA N D IEGO COUNTY TRAUMA SYSTEM ASSESSMEN Tv

1 SA N D I E G O COUNTY TRAUMA SYSTEM ASSESSMEN T

Executive Summary

Trauma care has been a significant part of theSan Diego healthcare landscape for 20 years.San Diego's trauma system is consideredby many to be one of the finest systems inthe country. Early leadership was demon-strated by the County Board of Supervisors,EMS Agency, hospitals and the HospitalCouncil of San Diego and Imperial Countiesby developing one of the first traumasystems in the country.

San Diego’s trauma system began in 1982when the Hospital Council of San Diego andImperial Counties conducted an assessmentto decide whether a trauma system wouldbenefit San Diego. The resulting study ledto development of the County's trauma careplan. Many refinements have been made tothe trauma system during its 18-yearexistence. This study was designed toevaluate the current system's capabilitiesand performance and make recommenda-tions for the future.

The current trauma system treats in excess of9,500 patients per year - with that volumeexpected to grow to 13,200 over the nextseven years. The trauma patient is served bya network of 18 9-1-1/PSAPs (public safetyanswering points), 24 basic and advanced lifesupport services (both ground and air), 8base hospitals and 6 trauma centers. Thesecomponents form the framework of thetrauma system delivery network with supervi-sion and leadership coming from the SanDiego County EMS Agency.

The County of San Diego and the communityof San Diego should be amply reassured thatthe network of prehospital providers andtrauma centers provides high-quality, state-of-the-art care. The system is supervised bya state-of-the-art EMS Agency. The commu-nity should have confidence that the traumasystem continues to provide a superiorlevel of service to its residents.

Quality achievement is a pervasive theme

among the trauma centers, and the com-mitment at the County and provider levelsis also excellent. In particular, the traumacenter program managers and medicaldirectors and the County operate as acohesive group. It is this cohesiveness thatallows the candor and self-examinationwhich is the backbone of the trauma centerquality review process.

The Abaris Group is unaware of any othertrauma system in the country where therehas remained, over time, the sense ofmutual commitment and depth of qualityreview as has been demonstrated in SanDiego.

There are emerging challenges for assuringa stable network of trauma centers in SanDiego and in the country:

§ Growing demand for services,coupled with diminishingcapacity;

§ Lack of adequate funding andcompensation for emergency andtrauma-related services;

§ Shortages in available workforce; and§ Increases in the cost of liability insur-

ance for hospitals and physicians.

Key to these challenges are the ongoingstaffing challenges for physician special-ists at trauma centers. While this physi-cian coverage has stabilized, this issueremains a serious threat to the San Diegotrauma network. Ongoing system andhospital strategic planning will be neededto prevent further physician issues and tomitigate the effects of the other stabilitychallenges described in the report.

With a trauma network as experienced asSan Diego’s, system stakeholders are alsoeager for continued improvements com-mensurate with assured quality and costefficiencies. There is also a significantdesire to see a financially stable traumasystem for the future.


The Abaris Group has summarized the keyrecommendations on system improve-ments that meet these goals:

(1) Refinement of the Medical AuditCommittee (MAC) is recommended toassure continued relevance, appropriateresource utilization and the identificationand management of system trends andstrategic issues.

(2) A comprehensive review of thetrauma triage criteria is needed to verifyassumptions on over-and under-triage andto assist with resource allocation.

(3) An effort should be made to im-prove the coordination and focus of pre-vention efforts to target more traumacenter epidemiological and strategicinitiatives and assist with reducing dupli-cation.

(4) A single, synchronized, system-wide and state-of-the-art trauma registry isneeded.

(5) Increased coordination efforts areneeded with the prehospital stakeholdersto allow for improved interfaces betweenthe trauma and prehospital care systems.

(6) No changes are recommended tothe trauma center configuration in terms ofnumber of centers and their location butcontingency planning should occur, if thereis an unforeseen change with the numberof trauma centers.

(7) A complete strategic planningprocess should be developed that encom-passes trauma system expectations, leader-ship needs, expectations of the County andthe resources needed to assure a stabletrauma system for the future.

(8) There is a need to create a linkedand integrated information and surveil-lance system that meets the priority goalsof the trauma system.

“Confirming the

infrastructure of the

trauma system and

addressing

the recommended

refinements in this

report will assure a

quality and stable

trauma system for

San Diego’s future.”

(9) Financial planning needs to occurat the trauma center and system levels toassure an ongoing stable and financiallysecure trauma system.

Confirming the infrastructure of the traumasystem and addressing the recommendedrefinements in this report will assure aquality and stable trauma system for SanDiego’s future.


I. Overview

Purpose

The Abaris Group was retained by the SanDiego County Board of Supervisors to assessand analyze the operations of the SanDiego County Trauma System and developrecommendations to improve the system'soperation and long-term stability. Thisassessment was based on analyzing variousdata and obtaining information, reviewingreports, conducting extensive interviews ofsystem stakeholders including representa-tives of the County, the designated traumacenters and other key system stakeholders,including fire, ambulance and otherprehospital care providers, other nontrauma center hospitals, and residents ofSan Diego.

Methods

The Abaris Group developed a detailedworkplan for the project which was approvedby the County of San Diego. During thestudy phase, The Abaris Group conductedan in-depth inventory of the six traumacenters and of the trauma system's Medi-cal Audit Committee process. An extensivenumber of interviews were conducted andfive town hall meetings of system stake-holders were completed. In addition, fourparamedic unit "ride-alongs" were con-ducted representing different geographicregions of the county. The interviews, townhall meetings and ride-alongs ultimatelyresulted in input from greater than 220system stakeholders whose information,comments and opinions were carefullyinventoried for this study. A project website also was established, allowing 24-houraccess to project details and documents.In addition to the interview and site visitprocesses, The Abaris Group conducted areview of the literature, interviewed othertrauma systems and reviewed and analyzeda number of databases.

A key component of the study methodologywas development of a baseline review andinventory of the trauma system and itscomponents.

The results of the inventory were publishedin the Trauma System Current StatusReport delivered to the County of SanDiego in November, 2002.

This report summarizes the observationsand conclusions of the trauma system studyby The Abaris Group.

“The interviews, town

hall meetings and

ride-alongs ultimately

resulted in input from

greater than 220

system stakeholders

whose information,

comments and

opinions were

carefully inventoried

for this study.”


Trauma System Develop-ment

Trauma System Defined

A trauma system may be defined as amultidisciplinary effort by a region to re-spond to the risk and occurrence of injury bycoordinating resources throughout the carespectrum. Such a system often involves theparticipation of the local public healthsystem, emergency medical services (EMS),designated trauma centers, rehabilitativecare and injury prevention programs. Traumasystems are developed with an expectationthat these efforts will lead to significantreductions in morbidity and mortality.

The National Highway Traffic SafetyAdministration’s (NHTSA) publicationTrauma System Agenda for the Future 1defines the infrastructure and fundamentalcomponents of a trauma system:

§ Acute Care Facilities§ Disaster Preparedness and

Response§ Education and Advocacy§ Finances§ Information Management§ Injury Prevention§ Leadership§ Post-Hospital Care§ Pre-Hospital Care§ Professional Resources§ Research Technology

The American College of Surgeons Consulta-tion for Trauma Systems2 document, ingeneral, mirrors the NHTSA model traumasystem components but specifies impor-tant details on such topics as systemdevelopment, legislation and research.This document additionally outlinescredentialing steps needed to identifyprogress and the status of each of the key

1 “Trauma System Agenda for the Future” , National Highway Traffic Safety Administration, Washington DC: October 2002.2 "Consultation for Trauma Systems", American College of Surgeons, Chicago, IL, 1998.3 Root GT, Christensen BH: Early Surgical Treatment of Abdominal Injuries in the Traffic Victim. Surg Gynecol Obstet 105:264, 1957.4 Van Wagoner FH: Died In a Hospital-A Three Year Study of Deaths Following Trauma. J Trauma 1:401, 1961.5 National Academy of Sciences and National Research Council, “Accidental Death and Disability: The Neglected Disease of Modern Society”. Washington, DC,1966

trauma system components.

The trauma system components identifiedby these documents form the backbone ofany quality trauma system in the country.

National Overview

It has only been in the past approximately 20years that highly developed trauma systemshave existed at all. There was some impetusfor their development as early as the late1950s and early 1960s, with the publicationof research studies reporting a need forimproved emergency treatment of injuries.3,4

The benefits of immediate treatment ofinjuries also became better known from theexperience of treating injured soldiers duringthe Korean and Vietnam wars. However, thefirst major step toward developing traumasystems came in 1966, when the NationalAcademy of Sciences and National ResearchCouncil published a white paper entitledAccidental Death and Disability: The Ne-glected Disease of Modern Society.5 Thisreport identified this country's significantdeficiencies in the provision of care forinjured patients and was instrumental inspurring the development of systems oftrauma care. That same year, the 1966Highway Safety Act was enacted, reinforcingthe states' authority to set standards, regu-late EMS and implement programs designedto reduce injury.

In the early planning years, urban hospitalsaffiliated with medical schools had thestaffing resources to provide timely treat-ment of injuries, but others did not. Illinoiswas a leader in establishing designatedtrauma centers in both urban and ruralareas. In the following years, Marylandestablished the Maryland Institute forEmergency Medical Services Systems(MIEMSS) and the first statewide traumasystem.


In 1973, the Emergency Medical ServicesAct (P.L. 93-154) was enacted to stimulatethe development of regional EMS systems.This act contributed significantly to thegrowth of the EMS infrastructure. Fifteenprogram components were recognized asessential elements of an EMS system,including clear identification of targetefforts for developing trauma systems.During 1981, this program ended and wasfolded into the Preventive Health andHuman Services (PHHS) Block GrantProgram.

Studies done in the late 1970s revealed highrates of preventable injury deaths. In 1983West, et al, conducted a comparison ofpreventable death rates pre- and post-trauma system implementation and found areduction from 73 percent to 9 percent.6

Numerous additional studies have sup-ported these conclusions.

In 1985, the National Research Council andLibrary of Medicine published another whitepaper entitled Injury in America—A Continu-ing Public Health Problem.7 Their reportconcluded that more needed to be done forinjury control. The report advocated in-creased resources for injury prevention andled to the creation of an injury preventioncenter under the Centers for DiseaseControl (CDC). Additional Injury ControlResearch Centers have since been estab-lished throughout the country.

After much debate and planning, TheTrauma Care Systems Planning and Devel-opment Act of 1990 (P.L.101-590) waspassed. The Act encouraged state govern-ments to develop, implement and improveregional trauma systems. The primary focusof the Act was the development by eachstate of a trauma care plan that takes intoaccount national standards for the desig-

nation of trauma centers and for patienttriage, transfer and transportation policies.Additionally, the Act created a Division ofTrauma and EMS (DTEMS) under theHealth Resources and Services Adminis-tration (HRSA). Funding was suspended inFY1995 but returned in FY2001. Twoimportant achievements of the DTEMShave been the development of a DraftModel Trauma Care System Plan andestablishment of competitive planninggrants for statewide trauma system devel-opment.8 This Draft Model Trauma CareSystem Plan has been instrumental inestablishing guidelines for trauma systemdevelopment throughout the country.

In 1999, the Institute of Medicine publishedReducing the Burden of Injury: AdvancingPrevention and Treatment, which foundevidence of progress in preventing andtreating injury, but advocated increasedfederal funding for greater improvements.9

At the trauma center level, the AmericanCollege of Surgeons Committee on Trauma(ACSCOT) has played a key role in establish-ing guidelines. The ACSCOT published thefirst guidelines for the designation of traumacenters in 1976, in a publication entitledOptimal Hospital Resources for Care of theSeriously Injured.10 These guidelines havebeen periodically updated and were mostrecently published in 1999 as Resourcesfor Optimal Care of the Injured Patient.11

In 1987, the ACSCOT also began a programin which the American College of Surgeons(ACS) provided evaluation of traumacenters, and more recently publishedConsultation for Trauma Systems, a set ofguidelines for evaluation and improvementof trauma systems.12

6 West JG, Cales RH, Gazzaniga AB: Impact of regionalization—The Orange County experience. Arch Surg 118:740, 1983.7 National Research Council and Library of Medicine. “Injury in America - A Continuing Public Health Problem”. Washington, DC, National Academy Press, 1985.8 Health Resources and Services Administration. “Draft Model Trauma Care System Plan”. Rockville, MD, Health Resources and Services Administration, 1992.9 Committee on Injury Prevention and Control, Institute of Medicine. “Reducing the Burden of Injury: Advancing Prevention and Treatment”. Washington, DC, National Academy Press, 1999.10 “Optimal Hospital Resources for Care of the Seriously Injured”. Bulletin of the American College of Surgeons, 61:15-22, 1976.11 American College of Surgeons Committee on Trauma: “Resources for Optimal Care of the Injured Patient”. Chicago, American College of Surgeons, 1998.12 American College of Surgeons Committee on Trauma: “Consultation for Trauma Systems”. Chicago, American College of Surgeons, 1998.

SA N D I E G O COUNTY TRAUMA SYSTEM ASSESSMEN T6

Other important guidance ontrauma systems has come fromthe American College of Emer-gency Physicians (ACEP) andNHTSA, as noted above. In 1987,ACEP published Guidelines forTrauma Care Systems, whichprovides guidance on all elementsof trauma system care.13 NHTSAdeveloped the first national guid-ing document on trauma systemsthrough its publication Develop-ment of Trauma Systems: A Stateand Community Guide.14 Thisdocument was the predecessor tothe Model Trauma System Planalso mentioned above. NHTSAestablished the Statewide Techni-cal Assessment Program, throughwhich “technical assistanceteams” were invited to review theEMS and trauma systems of statesacross the country. Three technicalassistance workshops were con-ducted, including one in Califor-nia. In addition, the Developmentof Trauma Systems Course byNHTSA was established to furtherassist the states.

In 1987, West, et al, defined eighttrauma system components andconducted a nationwide survey oftrauma system development.15 Thecomponents were: legal authorityto designate trauma centers, aformal process for designation,use of ACS standards for traumacenters, out-of-area survey teamsfor trauma center designation,designation based on need,written triage criteria, ongoingmonitoring of trauma centers, andfull state coverage by traumacenters. The survey found thatonly Maryland and Virginia had all

components including statewidecoverage, 19 states and the Districtof Colombia lacked one or more ofthe components for a traumasystem and 29 states had not yetbegun any process for traumasystem development. In a 1993survey, Bazzoli, et al, found that thenumber of states with completetrauma systems had increased tofive,16 and a 1998 survey conductedby Bass, et al, found that in additionto the 5 states meeting all 8 criteria,28 states met 6 to 7 componentcriteria, another 10 had less than 5,and 8 states had no trauma systemcomponents.17

California Overview

The California Legislature estab-lished the authority for traumasystem planning in 1984. Thepurpose of this statutory authoritywas to encourage development oftrauma care systems throughout thestate. During 2001, the Legislaturepassed AB1430 which reinforced thegoal of a state-wide trauma network.This legislation also approvedfunding for additional traumaplanning and for support to desig-nated trauma centers.

California trauma systems areregulated under the California Codeof Regulations, Title 22, Division 9,Chapter 7. These regulations definethe requirements for trauma sys-tems as well as trauma centers inCalifornia. In addition, they describethe roles of the local emergencymedical services (EMS) agency andthe California Emergency MedicalServices Authority (EMSA) in devel-

13 American College of Emergency Physicians: “Guidelines for Trauma Care Systems”. Ann Emerg Med 16:459, 1987.14 “Development of Trauma Systems: A State and Community Guide”. Washington, DC: NHTS, Washington DC.15 West JG, Williams MJ, Trunkey DD, Wolferth CC: Trauma systems: Current status - Future Challenges. JAMA 259:3597, 1988.16 Bazzoli GJ, Madura KJ, Cooper GF, et al: Progress in the Development of Trauma Systems in the United States. JAMA 273:395, 1995.17 Bass RR, Gainer PS, Carlini AR: Update on Trauma System Development in the United States. JTrauma. 47:S15, 1999.

Today, nationwide there are 1,078designated trauma centers (35states) and 1,149 designated orverified trauma centers (includingthe 15 states with 71 verified butnot designated trauma centers).

Exhibit 1United States Trauma Centers

§ 192 Level I§ 261 Level II

§ 242 Level III§ 451 Levels IV and V§ 3 Unspecified§ 1,149 Total

Source: American Trauma Society, 2002 Survey


oping local trauma systems. Californiatrauma regulations do not require traumasystems and trauma centers but merelystipulate the requirements for such asystem if established.

The EMSA provides statewide coordinationand leadership for the planning, develop-ment and implementation of local traumacare systems. EMSA responsibilities includedeveloping statewide standards for traumacare systems and trauma centers, theprovision of technical assistance to localagencies; developing, implementing, orevaluating components of a trauma caresystem, and the review and approval of localtrauma care system plans to ensure compli-ance with the minimum standards set by theEMSA.18 The trauma plan requirements inCalifornia address all of the issues identifiedby the NHTSA and ACS documents de-scribed above.

Local EMS agencies are responsible forplanning, implementing, and managinglocal trauma care systems, including assess-ing needs, developing the system design,designating trauma care centers, collectingtrauma care data, and providing qualityassurance.

Currently, California has trauma systems in20 of its EMS regions, and the goal is thatthe remaining 12 regions will develop, orfinish developing, systems in the nearfuture. There are currently 58 trauma centersacross California, including 14 with Level Idesignation, 31 at Level II, 7 at Level III, andthe remaining 6 at Level IV.

18 California Code of Regulations, Title 22, Division 9, Chapter 7.19 Amherst & Associates, Inc.: “Trauma Needs Assessment Study”. Prepared for the Hospital Council of San Diego and Imperial Counties, 1982.

San Diego County TraumaSystem

History of San Diego Trauma

Trauma care has been a significant part ofthe San Diego healthcare landscape for 20years. San Diego’s system is considered bymany to be one of the finest systems in thecountry. Early leadership was demonstratedby the County Board of Supervisors, EMSAgency, hospitals and the Hospital Councilof San Diego and Imperial Counties bydeveloping one of the first trauma systemsin the country.

The San Diego trauma system began in1982 when the Hospital Council of SanDiego and Imperial Counties conducted anassessment to decide whether a traumasystem would benefit San Diego. Theresulting study, The Trauma Needs Assess-ment Study by Amherst & Associates, ledto developing the County’s trauma careplan.19 The Amherst Study revealed that46.9 percent of trauma patients studiedreceived suboptimal care and that 21.2percent of the deaths were either frankly orpotentially preventable.

In 1983, an ad hoc Trauma Advisory TaskForce was created to further advance theCounty’s efforts in formalizing a traumasystem. Their recommendations includedadopting trauma standards which closelyfollowed the American College of Surgeonsguidelines for optimal care of the injuredpatient. A year later, the trauma system wasapproved by the San Diego County Board ofSupervisors.

In 1992, the San Diego County Board ofSupervisors reconvened the TraumaAdvisory Task Force to analyze the opera-tion of the system and develop recommen-dations to improve the system’s operationand long-term stability. The Trauma


Advisory Task Force was comprised ofapproximately 75 system stakeholders. Thetask force was divided into four subcom-mittees – fiscal, clinical, systems and legal– each of which reviewed and made recom-mendations on a set of “critical questions”pertinent to that subcommittee. Essen-tially, they found that the trauma systemworked well and did not need any majorchanges. The task force also made severalrecommendations for considerationthroughout the San Diego County traumacare community.

These two studies and others in San Diegohave contributed to many other traumasystems in the country. A number of theindividual trauma system stakeholdershave made significant additional contribu-tions to trauma systems throughout theU.S. These include extensive participationin development of the Model Trauma Planand its roll out (Cooper,Eastman and Hoyt),system site visits (Cooper,Eastman, Hoyt and Sise)and early involvement inthe California traumasystem regulations(Cooper, Eastman andHoyt).

David Hoyt, MD andother local trauma stake-holders have an ongoingrole in the development of a CaliforniaTrauma System Plan now under develop-ment.

Ten years later, in 2002, the Board ofSupervisors requested a further review ofthe trauma system and retained The AbarisGroup to conduct this third assessment.

Outcome Changes

A clear affirmation of the success of theSan Diego trauma system is the significant

20 Shackford SR, Hollingsworth-Fridlund P, Cooper GF, Eastman AB: The Effect of Regionalization upon the Quality of Trauma Care as Assessed by Concurrent Audit before and after Institution of a Trauma System: A Preliminary Report. J Trauma 26:812, 1986.

decrease seen in the number of prevent-able deaths and the generally improvedcare that has resulted since implementingthe trauma system. Two important studiesexamining outcome changes have beenconducted in San Diego. The first study,conducted by Shackford, et al, in 1984,compared the trauma system beforeimplementation and after.20 This studyused data from the original Amherst Studyfor the pre-trauma center system analysisbut followed a more stringent reviewprocess of that data. The same reviewprocess was then used for the post-traumacenter implementation portion of thestudy.

The “before” and “after” study demon-strated that before the trauma system wasregionalized, the care of major traumavictims was considered suboptimal in 32percent of cases. After the system was

regionalized, the number of patients whoreceived suboptimal care dropped to 4.2percent. With respect to preventabledeaths, before the system was regional-ized, 13.6 percent of major trauma deathswere identified as “preventable.” Afterregionalization, “preventable” deathsdropped to 2.7 percent.

The projected annualized number of“frankly preventable” deaths identifiedduring the Amherst Study (1982) thatsurvived after trauma center designation(1984) was 28.8 patients per year. Assum-

San Diego Trauma Center Network Before After

Suboptimal Care

Preventable Death

Suboptimal Care

Preventable Death

32% 13.6% 4.2% 2.7%

Exhibit 2 - Rates of Suboptimal Care and Preventable DeathBefore and After Trauma System Implementation

Source: Shackford, Hollingsworth-Fridlund, Cooper and Eastman, 1986


ing the same preventable death rate afterdesignation, with no adjustments forvolume growth, the number of saved liveswould be 518 during the trauma centernetwork’s 18 year existence.21

In 1986 a second study was conducted byShackford, et al, to understand the out-comes at hospitals that were not traumacenters versus those that were.22 Theresults showed that the percent of prevent-able deaths occurring at non-traumahospitals was 7.6 percent, while at traumacenters it was 2 percent. The data andevidence that resulted from both of thesestudies have helped propel and propagatetrauma systems throughout the country.

Two other highly successful componentsof the San Diego County trauma systeminclude the Medical Audit Committee (MAC)and the highly collaborative nature withinthe trauma stakeholder groups. MAC is thetrauma system quality assurance committeethat includes the trauma medical directorsand the trauma program managers fromeach trauma center, among others. WhileMAC meets monthly, every other month theymeet to discuss trauma cases, with candiddiscussion of case treatment between thepeer trauma centers. On the alternatemonths the committee discusses adminis-trative and system issues.

The high level of collaboration among thekey trauma stakeholders has been identifiedas a unique strength of the San Diegosystem. It is apparent that the traumamedical directors and trauma programmanagers confer regularly even outside ofthe MAC process on important traumacenter issues. In addition, many other keystakeholder groups communicate regu-larly, including the sister committee toMAC, the Prehospital Audit Committee(PAC). The PAC generally operates simi-

larly to MAC, but has a wider participationbase (ambulance providers, emergencydepartment physicians, base hospitalcoordinators, etc.).

It is believed by system stakeholders that allof these components and others havecontributed to the culture of quality reviewand the overall success of the San DiegoCounty trauma system.

San Diego Trauma Today

The San Diego trauma system is com-prised of five adult and one pediatrictrauma center. Trauma center admissions

have steadily increased since the system’sinception. From fiscal year 85/86 to fiscalyear 01/02, trauma center admissions haverisen 118 percent. The average annualgrowth rate has been 7 percent per year.Exhibit 4 shows the number of traumacenter admissions by fiscal year, themonthly average, the percent change andthe utilization rate per 100,000 popula-tion. With the steady rise in trauma cases,the utilization rate is also increasing. Infiscal year 85/86 the utilization rate (num-ber of trauma cases per 100,000 popula-tion) was 203.6. For fiscal year 01/02 theutilization rate was 327.1.

21 Based on calculations by The Abaris Group.22 Shackford SR, Hollingsworth-Fridlund P, McArdle, Eastman AB: Assuring Quality in a Trauma System - The Medical Audit Committee: Composition, Cost, and Results. J Trauma 27:866, 1987.

“It is believed by

system stakeholders

that all of these

components and

others have contrib-

uted to the culture of

quality review and the

overall success of the

San Diego County

trauma system.”

San Diego County Trauma System

Trauma Centers Level

Children's Hospital & Health Center II

Palomar Medical Center II

Scripps Memorial Hospital - La Jolla II

Scripps Mercy Hospital & Medical Center II

Sharp Memorial Hospital II

UCSD Medical Center I

Exhibit 3 - San Diego Trauma Centers


Exhibit 4 - Trauma Center Admissions by Fiscal Year

Trauma Center Admissions by Fiscal Year

Fiscal Year July - June

Trauma Center

AdmissionsMonthly Average

Percent Change

Rate per 100,000

Population85/86 4,374 365 - 203.686/87 5,466 456 25% 245.887/88 6,148 512 12% 267.288/89 6,379 532 4% 267.189/90 6,650 554 4% 268.190/91 7,036 586 6% 277.191/92 7,111 593 1% 275.392/93 6,460 538 -9% 247.193/94 6,399 533 -1% 242.594/95 6,474 540 1% 243.595/96 7,516 626 16% 279.496/97 7,257 605 -3% 266.497/98 7,653 638 5% 273.898/99 8,435 703 10% 295.699/00 8,984 749 7% 308.600/01 9,351 779 4% 327.001/02 9,545 795 2% 327.1

Source: SDEMSA San Diego County Trauma System Report, SANDAG.

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

85/86 87/88 89/90 91/92 93/94 95/96 97/98 99/00 01/02

San Diego County Trauma Center Admissionsby Fiscal Year


The following exhibit illustrates the inci-dence rate of trauma triage in other coun-ties to trauma centers in California. Datawere collected from local EMS agencies on“total number of patients triaged to atrauma center” for calendar year2001. The incidence rate wasthen calculated using the 2001population estimate for eachcounty or region from the Cali-fornia Department of Finance.The population data used tocalculate the incidence rates arefor the resident population in thecounties. Neither visitors norundocumented immigrantpopulations are included in anyof the population statistics andmay have an impact on thesecalculations.

The regions with the highesttrauma incidence rates were SanDiego (321.2/100,000), Marin(318.6/100,000) and ContraCosta (290.6/100,000).

Comparisons between EMSregions are difficult due toregional variations in the data availability,the impact of temporary populations, andthe use of the definition “triaged to traumacenters”. The chart does reflect an indica-tion of considerable variation in triagerates by regions.

Future of Trauma

Looking to the future, trauma systemscontinue to be developed and improvedthroughout California and across thecountry. NHTSA’s Trauma System Agendafor the Future envisions further integrationof injury prevention, acute care and reha-bilitation programs in order to achieve anunderstanding of all trauma care needsthroughout the trauma care continuumand how they can be met. Continuedresearch, improved technology, and apply-ing what is already known are helping

make this goal possible. Federal fundingfor trauma systems continues to be achallenge as the overall Federal budget isadjusted for changes in the economy andother funding priorities. However, the

threat of terrorism has created renewedinterest in a national trauma systemnetwork and may add additional momen-tum for system development.

There are emerging challenges for assuringa stable network of trauma centers in thecountry:

§ Growing demand for services,coupled with diminishingcapacity;

§ Lack of adequate funding andcompensation for emergency andtrauma-related services;

§ Shortages in available workforce; and§ Increases in the cost of liability insur-

ance for hospitals and physicians.

Ongoing system development will requirecareful consideration and planning formitigation of the effects of these trends.

Exhibit 5 - California County Trauma System Comparison

California Trauma Incidence Rate (Per 100,000 Population)

Local EMS AgencyTotal Trauma

Triages 2001Population

2001

Incidence Rate/

100,000 Population

San Diego 9,285 2,890,600 321.2Marin 793 248,900 318.6Contra Costa 2,839 977,000 290.6Alameda 4,053 1,475,800 274.6Santa Clara 4472 1,706,400 262.1Northern California1 1,533 604,100 253.8Santa Barbara 1,003 405,700 247.2Inland Counties (San Bernardino, Inyo, Mono) 4,144** 1,797,450 230.5Riverside 3,459** 1,618,000 213.8Sierra-Sacramento Valley2 1,331 672,500 197.9Los Angeles 18,837 9,748,500 193.2Sacramento 2,345 1,267,800 185.0Kern 1,200** 681,900 176.0San Mateo 1,133 714,500 158.6San Francisco 1,131** 789,600 143.2Fresno, Kings, Madera 1,436 1,084,700 132.4Coastal Valleys (Mendocino, Napa, Sonoma) 696** 684,000 101.8Merced 218 216,400 100.7Orange 2,659 2,910,000 91.4

Source: Individual CA Local EMS Agencies, CA Department of Finance, The Abaris Group.

1 Northern California is comprised of Butte, Colusa, Glenn, Lassen, Modoc, Plumas, Shasta, Sierra, Siskiyou, Tehama & Trinity Counties; Sierra-Sacramento Valley is comprised of Nevada, Placer, Sutter, Yolo & Yuba Counties.

2The Inland Counties figure is for patients meeting trauma registry criteria only; the Kern County figure is approximate because theirs is a new system; in Coastal Valleys, an additional 617 patients met trauma triage criteria but were transported to a non-trauma center due to mitigating factors; the San Francisco figure consists of patients admitted to trauma and neurosurgery services, but not orthopedics or other specialties; the Riverside figure represents trauma activations at centers using different criteria until Jan 2002.


II. Inventory ofResources

Overview

As part of the San Diego County TraumaSystem Assessment Study, The AbarisGroup conducted numerous site visits toeach trauma center and interviewed greaterthan 220 key stakeholders to obtain theirinput. A thorough review of historicalreports and documents was also com-pleted. Using these three avenues, TheAbaris Group was able to inventory re-sources relevant to the trauma system inSan Diego County.

Prehospital Care

Dispatch

Following a traumatic injury, access tomedical care is most often achievedthrough calls to the Enhanced (E) 911system, which is available throughout SanDiego County. E-911 calls are delivered toone of 18 primary Public Safety AnsweringPoints (PSAPs) or 16 secondary PSAPs. ThePSAP dispatcher determines the need forpolice, fire or medical assistance. A reviewof all of the dispatch entities in SanDiego’s medical priority dispatch systemwas not part of the scope of this project,but interviewees reported that dispatchthrough the PSAP to the provider agencyoccurs seamlessly. However, the numberof agencies and the fact that they do not fitunder the authority of the EMS Agency isone of the barriers to creating a linkedPSAP-to-patient outcome database.

The City of San Diego has the largestpopulation and the most EMS responsesin San Diego County. The City has dispatchcenters with San Diego Fire and RuralMetro staff. Sophisticated CAD (computer-ized-aided dispatch) with AVL (automaticvehicle location) is used universallythroughout the City. This CAD system is

being integrated into the portable comput-ing documentation system San Diego Fireis using. San Diego City calls are dividedinto four categories based on the priorityof response, which presents challenges inall advanced life support (ALS) responsesystems. Aggressive quality assurance(QA) on the required number of calls isperformed monthly by San Diego CityDispatch. Issues about the quality ofadvice and appropriateness of the type ofdispatch and unit are all appropriatelyevaluated. Dispatchers have expressed aneed for more training and personnel.

Transporting Agencies

The San Diego County trauma system issupported by the following types ofprehospital transporting agencies:

The 15 ALS providers provide service to theentire county and are supported by the 8basic life support (BLS) providers. In addi-tion, all fire departments (34 in the SanDiego region) act as first responders.

Air-Medical System

The region has a single private provider ofair medical services, Mercy Air, whichprovides two helicopters for the county andhas backup capabilities in the region. Thesehelicopters are located in strategic areas andprovide timely response and comprehensivecoverage to the region. Mercy Air fliesapproximately 1,500 flights per year withinthe region. Significant use occurs in thenorthern portions of the county due to longtransport times. There is variation in use,as some jurisdictions in the north use

San Diego County Trauma SystemTransporting Agencies CountAir Medical w/ Advanced Life Support 1Advanced Life Support (ALS) 15Basic Life Support (BLS) EMT-I 8EMT-Defibrillation Agencies 40Private Ambulance Providers 6

Exhibit 6 - San Diego CountyTransporting Agencies


Mercy Air extensively for trauma transportswhile adjacent communities do not.

Mercy Air’s crew (approximately 80) arehighly trained, with staffing configurationsranging from nurse with physician to nursewith paramedic and an on-scene timeranging from 15 to 20 minutes. Air medicalprotocols are a superset of the San DiegoCounty EMS protocols and there is arigorous quality assurance process.

Coordination between ground and air-medical crews is excellent. In most cases,ground units are well-versed in air-medicalinterfaces. Some of the more rural agen-cies require additional outreach to educatea volunteer workforce. Reception of air-medical crews by trauma staff has beenuniversally excellent with adverse interac-tion occurring only on rare occasions.

Base Hospitals

In addition to the transporting agencies,base hospitals play a key role in the fieldtriage of the trauma patient. Prehospitaltreatment and patient destination deci-sions are made through consultation withthe base hospital physician or mobileintensive care nurse (MICN). In general,

base hospital radio contact for a potentialtrauma center patient is made to thetrauma center destination (should thepatient require trauma center care) toallow for continuity of care and communi-cation. The exception is for suspected

pediatric trauma patients for whom radiocalls are managed by Sharp MemorialHospital. In addition, the base medicaldirector and nurse coordinator monitoroverall prehospital care, and are in turnmonitored by the EMS Agency. Each basehospital has a committee that maintainscommunication with other hospitals intheir catchment area and the assignedprovider agencies. In addition, the BaseHospital Nurse Coordinators Committeeis a countywide committee that meets todiscuss the prehospital and base hospitalcare of patients and make recommenda-tions to the EMS Agency. Similarly, theBase Hospital Physicians Committeemakes recommendations to the EMSAgency and its medical director.

Through their frequent provision of on-linemedical control, MICNs act as the backboneof the base hospital system. They conferwith the EMS provider during transport andenter information into the County’s commu-nication and information system, theQANet, which is immediately available tothe receiving hospital. MICNs also provideaudits of the system and examine compli-ance with protocols. MICNs have at leastone year of emergency department experi-ence, ambulance ride-along experience,and familiarity with QANet. Some areTrauma Nurse Core Course (TNCC) certi-fied.

Communication

The county is covered by an coordinated800 MHz system. This system is unifiedand provides consistent communicationbetween all public safety members andhospitals including the rural areas of thecounty.

EMS ProtocolDevelopment

EMS protocol development in San DiegoCounty is mature and involves mostprehospital stakeholders. Countywide

San Diego County Trauma SystemBase HospitalsGrossmont Hospital - Sharp HealthcarePalomar Medical CenterScripps Memorial Hospital, Chula VistaScripps Memorial Hospital, La JollaScripps Mercy Hospital and Medical CenterSharp Memorial HospitalTri-City Medical CenterUCSD Medical Center - Hillcrest

Exhibit 7 - San Diego Co. Base Hospitals


protocols are in place and do much toenhance the integrity of the system. Thereare some differences in opinion betweenmedical directors regarding some inter-ventions.

There is a Protocol Task Force that isannually established by the County EMSMedical Director to review all treatmentprotocols for potential revision. As part ofthat task force, additional “treatments”have been added to the list of “standingorders” thus making a gradual move to“off-line” versus “on-line” medical con-trol. The task force is also developingmore evidenced-based prehospital proto-cols.

While there have been improvements, thecurrent prehospital protocols remainpredominately aligned to the “on-line”medical control model of EMS providerscalling the base hospital for orders. Thereis a prevalence of EMS systems in thecountry orienting to more “off line”medical control.

Committees & Evaluation

San Diego County has approximately 18trauma/EMS-related committees, somedealing directly with trauma and the re-maining addressing trauma/EMS issues asappropriate. The primary trauma qualityreview committee is the Medical AuditCommittee (MAC). However, thePrehospital Audit Committee (PAC) alsoparticipates in quality review of EMS com-ponents that affect the trauma system.

MAC is a critical component of the SanDiego County trauma system. MAC auditspatient care in the trauma system on acontinuing basis. The committee wasestablished at the inception of the traumasystem and consists of representatives fromall designated trauma centers as well asother facilities and key clinical groups (e.g.base hospital, orthopedic society, neurosur-gical society, County Medical Examiner,

etc). MAC is operationally supported byEMS Agency staff. Cases are initiallyreviewed at the trauma center level andthen forwarded through a formal Pre-MACprocess for consideration for MAC review.Deaths are identified following review bythe Medical Examiner. The autopsies andother Medical Examiner reports of alltrauma-related deaths are sent to MACparticipants for review. Cases that raisequestions or are of significant educationalinterest are then forwarded to MACthrough the Pre-MAC process. Addition-ally, the EMS Agency QA Specialist forTrauma reviews scene deaths and forwardscases that raise questions.

The County Paramedic Agency Committee(CPAC) includes representatives from eachparamedic agency and is a forum fordiscussion of issues relating to prehospitalcare. The Prehospital Audit Committee(PAC) is a multidisciplinary committeecomposed of both prehospital and hospitalrepresentatives that reviews prehospitalcare. PAC has a member appointment toMAC to provide a linkage to the traumasystem quality assurance process.

Another key committee is the EmergencyMedical Care Committee (EMCC). TheEMCC is responsible under state statute formonitoring ambulance operations andemergency medical care provided in thecounty. This committee is the primaryadvisory group to the EMS Agency and theBoard of Supervisors on all aspects ofEMS. The EMCC consists of 18 members,all appointed by the Board of Supervisors.Thirteen of the members are drawn frompublic service and safety agencies involvedin EMS, and each of the five county Supervi-sors selects one additional public memberto represent their district’s interests.

There are also numerous state and Federalcommittees active in San Diego thatimpact EMS and the trauma system in SanDiego.

“There is a prevalence

of EMS systems in the

country orienting to

more “off line”

medical control. “


Exhibit 8 provides a list of committees,linked to or directly active in San DiegoCounty.

ED Diversion

Like a majority of urban communities,ambulance diversion is a major concern inSan Diego County. Diversion hours aver-aged approximately 4,224hours per month for the 21hospitals in the region duringthe period January 2001through September 2002. Thisrepresents approximately 28percent of the total monthlyavailable hours. A majorinitiative was started in Octo-ber 2002 that reduced diver-sion hours for the last threemonths of 2002 by 74 percentcompared with the rest of theyear. This San Diego initiativehas contributed significantly tothe improvement of the pre-hospital and hospital systemsand the patients that theyserve.

The ED diversion initiative is acollaborative process amongthe hospitals to allow patientsto be transported by ambu-lance to their preferred hospi-tal (except where prevented bythe patient’s medical condi-tion) even if the hospital is ondiversion. The first month ofthe initiative (October 2002)saw the most success, with 752 diversionhours that month (a 79 percent reductionfrom October 2001). Diversion hours forNovember (1,042) and December (1,443)rose from October’s low, but were stillsignificantly lower that the hours for thosemonths in 2001 (3,275 and 3,592, respec-tively).

Trauma center bypass hours have beenconsistently low over the years. There is

one minor exception during this time-frame, when Palomar Memorial Hospitalwent on extended trauma bypass duringthe month of December 2001 (related totrauma physician contract issues). Traumacenters have been averaging 6 to 15 hoursof trauma bypass per month, with theexception of Children’s Hospital, whichaveraged less than one hour of trauma

bypass per month during 2002. San DiegoED diversion hours for trauma centers varyin comparison to other EDs in San DiegoCounty. Some have higher ED diversionhours and some lower than countywideaverages.

Exhibits 9 and 10 provide a summary of EDdiversion and trauma bypass hours for2001 and 2002.

“This San Diego

initiative has contrib-

uted significantly to

the improvement of

the prehospital and

hospital systems and

the patients that they

serve.”

Exhibit 8 - San Diego Co. CommitteesSan Diego County Trauma SystemCommitteesFederal/National

Metropolitan Medical Response System (MMRS)National Disaster Medical System (NDMS)

StateCalifornia Council of Local Health Officers (CCLHO) (EMS/Med Disaster)California Specialized Training Institute (CSTI) Advisory BoardEmergency Medical Directors Association of California (EMDAC)EMS Administrators' Association of California (EMSAAC)EMS CommissionRegional Disaster Committee

RegionalRegion VI State Disaster Medical and Health Operations Coordinators

LocalBase Hospital Committees (at each base hospital)Base Hospital Nurse Coordinators CommitteeBase Hospital Physicians Committee (BSPC)Basic Life Support Operations Quality Improvement Task ForceCounty Paramedic Agency Committee (CPAC)CSA 17 Advisory BoardCSA 69 Advisory BoardEmergency Medical Care Committee (EMCC)Emergency Nurses AssociationFire Chiefs AssociationHazardous Material Advisory BoardHealthcare Association of San Diego and Imperial CountiesMedical Audit Committee for Trauma (MAC)Metopolitan Medical Response SystemPrehospital Audit Committee (PAC)San Diego County Medical SocietySan Diego Terrorism Early Warning GroupSan Diego Terrorism Working Group


Information Systems

EMS providers are expected to complete abubble form or directly enter data into theQANet for each EMS response. The Countythen scans these forms and merges thatdata with data from the QANet into asoftware analysis tool (SPSS). There is aconsiderable backlog of scanning. Thereare many reasons for this including thetime lag from the event to receipt of theforms by the County, incomplete formsand the County’s information systemconsultant has been unable to produce

programs necessary to complete thefunction in a timely manner. Some juris-dictions like the City of San Diego havedeveloped their own redundant trackingand scanning systems. A major overhaul ofthe County’s information system is under-way at this time.

Special Studies

Throughout the existence of the traumasystem, periodic studies and discussions oftrauma protocols, triage standards andcatchment areas have taken place within thetrauma committee structure. Approximatelytwo years ago there was considerable

SD County ED/TraumaDiversion Hours

0

1000

2000

3000

4000

5000

6000

7000

J F M A M J J A S O N D Months

ED H

ours

0

50

100

150

200

250

300

350

400

450

Trau

ma

Hou

rs

ED 2001

ED 2002

Trauma 2001

Trauma 2002

Exhibit 9 - San Diego Co. ED / TraumaDiversion Hours

Trauma Center Diversion/Bypass Hours - Average Per Month

Children'sScripps

Mercy PalomarScrippsLa Jolla

Sharp Memorial UCSD

2001 2.7 6.4 42.7 5.6 9.2 7.22002 0.8 6.3 14.6 10.9 11.9 6.6

2001 4.9 229.1 152.9 282.1 220.0 284.62002 1.8 183.3 109.4 226.5 167.5 220.7

Source: SDEMSA QANet, 1/01-12/02Note:The average SD ED monthly diversion hours for 2002 was 162 hours/month

Average Trauma Bypass Hours

Average ED Diversion Hours

Exhibit 10 - Trauma Center AverageMonthly Diversion Hours


discussion about the catchment areas,particularly in the Mission Beach area, dueto a desire by the City of San Diego FireDepartment to establish definitions moreclosely fitting roadway and other geo-graphic markers. This discussion at MACwas tabled due to a lack of impact data.During 1992, there was a trauma triagestudy (Erickson Study) that evaluatedtrauma triage and again in 2000 there wasa workgroup on trauma triage that evalu-ated triage standards in comparison to theAmerican College of Surgeons “GoldBook”, which had recently been publishedand is a source of national standards fortrauma center systems. This latest studyused methodologies to look at over- andunder-triage but resulted in only modestchanges to the San Diego County traumatriage standards however the changes thatwere made now more approximate that ofthe American College of Surgeons.

A recent trial study referred to as the“physician variation” study was conductedfor three months during 2002 (March -May). This study allowed field personnel,in conjunction with the base hospital, toidentify an injured patient who does notmeet the trauma center patient criteria butfelt to be of high risk to bypass a localemergency department (ED) for directtransport to an ED with a trauma center. Thepatients in the study were evaluated by atrauma center ED clinical team but notnecessarily by the trauma clinical team. Thepurpose of the study was to determine ifthere were additional patients that wouldneed a trauma center assessment even ifthey did not meet the direct trauma patienttriage criteria. Of the 109 patients whoqualified during the trial study, 10 (or 9percent) were upgraded to full traumaactivation after arrival to the trauma center’sED. Six of those patients ultimately qualifiedfor entry into the San Diego County TraumaRegistry.

Trauma Centers

A detailed inventory by The Abaris Groupat all six San Diego trauma centers re-sulted in identifying resources used forthe trauma program. All six trauma centersmet or exceeded the clinical standards fortrauma center as promulgated by theCounty of San Diego EMS Agency. Theclinical equipment and policy inventorycompleted by The Abaris Group demon-strated compliance with the standard ofpractice for trauma centers.

All six trauma centers exhibited completecall schedules for all of the requiredspecialties. At various times there aredifficulties with highly specialized physi-cian coverage (e.g. hand surgery, ENT, etc)that appears to be based on the verylimited availability of such specialists inthe community. These cases are managedexpeditiously by using alternative special-ists or by transfer to another trauma centerwith that specialty’s coverage.

While there have been some historicalgaps in coverage by on-call specialists attrauma centers (specifically Palomar),coverage is currently being met. Obtainingstable on-call physician specialty coverageat trauma centers is an ongoing endeavorand will likely continue to challenge thetrauma centers in the future.

Three hospitals (Children’s, Scripps Mercy,and UCSD) have extensive teaching hospitalcommitments and resident involvement intrauma cases. Teaching hospital commit-ments include significant education effortsin the form of conferences, seminars andfaculty-supervised quality assurance ses-sions.

Each trauma center has a designatedtrauma medical director. The traumadirectors spend considerable amount oftheir time on the management of thetrauma center. All six trauma centers havedesignated trauma nurse coordinators/program managers. For the last two years,

“Obtaining stable on-

call physician

specialty coverage at

trauma centers is an

ongoing endeavor and

will likely continue to

challenge the trauma

centers in the future.”


the Palomar trauma program managerposition was covered by the Director ofEmergency and Trauma Services. Theposition has now been filled with a fulltime trauma program manager. Children’strauma program manager in the past wasallocated less than full time to trauma andthere is a report that at least one othertrauma program manager was functioningfor a time in less than a full time capacityfor the trauma center. The remainingtrauma centers have always had full timeprogram managers with 100 percent oftheir time on trauma center activities. Thelack of trauma program managers func-tioning in a that role in a full-time capacityhas impacted some trauma centers’performance.

There are significant injury preventionprograms at all six trauma centers andthere is cooperation among the traumacenters on prevention and educationalactivities through the trauma center-sponsored Trauma Research and Educa-tion Foundation (TREF). Four hospitals(Children’s, Scripps Mercy, Sharp Memo-rial and UCSD) have extensive hospital-based trauma public education and pre-vention programs with designated fundingand staffing.

Research is a system-wide commitmentunder the leadership of a comprehensivetrauma research commitment at UCSD. TheSan Diego trauma system has contributed alarge percentage of the sentinel publishedresearch articles on trauma systemsthroughout the country. The publication oftrauma research continues, primarily inbench and clinical research areas. Each ofthe trauma centers and the County EMSAgency extensively participate in the CrashInjury Research and Engineering Network(CIREN) crash research study, which isinvestigating ways to re-engineer automo-biles to reduce crash-related injuries.

Each hospital has an internal qualityassurance process for trauma. While eachtrauma center uses different methodolo-gies, they all follow the guidelines definedin the trauma quality assurance policiespublished collaboratively between theCounty and the trauma centers and casesrequiring further review are forwarded toMAC for additional review.

Emergency Departments

There are 21 emergency departments (ED)in the county of which six include traumacenters. Some trauma cases appear toarrive at non-trauma centers (See Exhibit54), but there are protocols and systemexpectations that the trauma patients bepromptly transferred to a trauma center.There is reporting by the Base Hospital tothe PAC on under triaged cases for arrivalsto the Base Hospitals only.

There are indications that EDs in SanDiego County are experiencing the samelevel of difficulty in obtaining subspecialistback up for their ED as the trauma centers.Some EDs will transfer patients withinjuries that do not meet the triage criteriato the trauma center or a partner hospital(e.g. Scripps, Sharp) with varying degreesof success and speed. There were strongindications during this study that somenon trauma center hospitals use thecatchment zone trauma center as theirED’s safety net for difficult to obtainsubspecialist coverage, commonly forneurosurgical and orthopedic coverage.This developing trend of using traumacenter physicians for non-trauma centerpatients exerts additional pressure on thealready fragile trauma center staffing forthese specialties.

“This developing

trend of using trauma

center physicians

for non-trauma

center patients

exerts additional

pressure on the

already fragile

trauma center

staffing for these

specialties.”


System Leadership

Board of Supervisors

The original trauma studies were sup-ported by the Board of Supervisors, andthere has been continued support by theBoard to develop and maintain a stabletrauma system. Their creation of a leader-ship and data structure within the EMSAgency and their efforts in the ongoingprocess of prioritizing identified funds forthe trauma centers are a clear indicationof their commitment to the traumasystem.

San Diego County EMSAgency

The trauma system is one component ofthe San Diego County EMS Agency’sresponsibilities. Within the EMS Agency,the EMS Chief is responsible for overallmanagement, planning, coordination,monitoring and evaluation of the traumasystem. The EMS Medical Director, whoreports to the Chief, provides medicalcontrol, which includes development andapproval of medical treatment protocols,continuous medical quality assurance andparticipation in agency research projects.The EMS Coordinator for Trauma, alsoreporting to the Chief, provides additionalcoordination and oversight of the traumacare system. The senior EMS Agencyleadership staff have considerable experi-ence and provide important role of neu-trality and direction to the trauma system.

The EMS Agency has undertaken a num-ber of strategic moves. In addition to thisstudy, they are overhauling the QANet atconsiderable county expense. They arealso completing the initial planning for acomprehensive EMS system review thatwould likely start some time in 2003.

The EMS Agency does not face the frictionwith private and public ambulance services

as is typical of other urban areas in thestate. This has been attributed to theoperating style of the EMS Agency, requir-ing accountability but delegating ambu-lance franchise authority to local commu-nities.

The EMS Agency employs an EMS Coordi-nator and a Trauma Program QA Specialistwho are responsible for coordinating allaspects of performance improvement andoverseeing the trauma registry. Addition-ally, a Senior Epidemiologist and staffreview and analyze data provided to theEMS Agency, supervise the trauma registryand prepare reports. Finally, there issupport staff to assist with all other needsas directed.

The EMS Agency epidemiologist andsurveillance staff are worthy of special notegiven their exceptional capability andcontribution to the EMS and traumasystem. Staff are assigned to the prehospi-tal database, while others are assigned tosupport the grant-funded Safe Communi-ties program. There are also staff assignedto the trauma registry and Medical Exam-iner database. Many of these positions areshared, but demonstrate the array anddepth of capabilities of the EMS Agency.This resource also results in identificationand early recognition of injury and medicalchief complaints through the surveillancesystem. It is through this system that“leading cause” cases are identified andtrends may be spotted. Even as such,reporting of trauma system trends andtheir use is limited in the current traumasystem.

The San Diego County EMS Agency hassubstantial responsibility for traumasystem oversight. There is an annual auditof trauma centers conducted by Countystaff that reviews trauma center capabili-ties against the trauma center standards.Every three years County staff coordinatesa review of the trauma centers by theAmerican College of Surgeons. Further-more, the County coordinates the distribu-

“The EMS Agency

epidemiologist and

surveillance staff are

worthy of special note

given their excep-

tional capability

and contribution to

the EMS and trauma

system.”


tion of state funds to the trauma centersand traffic fine surcharges to all hospitalsusing formulas defined by the underlyingauthority of the parent statute. It is notedthat the County has prioritized some ofthese funds for trauma center use. Countystaff coordinate the preparation of MACmaterials and attend all MAC meetings.

The County also has responsibility for themanagement and oversight of the system’strauma registry. Annual reports are pre-pared regarding system demand and itscharacteristics. There are a number ofother EMS Agency staff that participate intrauma system activities specific to theirarea of agency focus. For example, theprehospital and base hospital staff of theEMS Agency have participated in severalspecial studies of the trauma system inwhich prehospital coordination wasneeded.

In addition, the EMS Agency maintains theQANet which is a real time, computerizedwide area network that is used to collectand store patient information, hospitalresource availability and to link EMSresources. The QANet allows providersterminal data entry at the provider site.This system, along with the scanning ofprehospital bubble forms, allows theCounty to monitor EMS system activitiesand allows countywide prehospital analysisspecific to trauma patients.

County staff provide another source ofinterface and continuity within the EMSsystem through their attendance at MACmeetings and other advisory committeesthroughout the county.

Trauma Center Leadership

As noted previously, each designatedtrauma center is led by a trauma medicaldirector and trauma program manager. Thetrauma medical director is responsible forthe medical direction of the trauma pro-gram, participation in Pre-MAC and MAC,trauma rounds, and other activities. The

trauma program manager is responsiblefor coordinating the trauma program,overseeing the trauma registry, and partici-pating in the Pre-MAC and MAC processas well. The trauma program managershave additional duties that are specific totheir individual trauma center configura-tions and priorities. Additional staff at thetrauma center level includes trauma casemanagers, trauma registrars, traumanurses, etc. Half of the trauma medicaldirectors and trauma program managers inthe San Diego County system have beentrauma system participants in excess often years and the remainder have signifi-cant trauma, hospital and EMS experience.

Other System Components

Rehabilitation Facilities

Rehabilitation of trauma care has beenseen as a critical resource for traumapatients to improve their functionality andquality of life. Trauma center rehabilitationis a fully integrated component of the SanDiego trauma system approach to injurycare and completes the trauma systemconcept in San Diego. San Diego Countyhas five rehabilitation facilities for spinalcord and head injuries. These facilitieshave transfer agreements with the traumacenters. The rehabilitation facilities are:

Burn Care

Burn care is provided at UCSD MedicalCenter’s Burn Center. This facility hastransfer agreements with the traumacenters.

San Diego County Trauma SystemRehabilitation FacilitiesChildren's Hospital Rehabilitation CenterPalomar Hospital Rehabilitation ServicesSan Diego Rehabilitation InstituteScripps-Encinitas Rehabilitation ServicesSharp Rehabilitation Services

Exhibit 11 – San Diego County


Study of Best Practices

The Abaris Group conducted an inventory ofbetter and best practices in trauma systemsnationally. This was to provide a frame forreviewing San Diego County’s traumasystem in perspective to other traumasystems’ practices throughout the country.

The best practice survey was conductedthrough telephone interviews. The 15 mostlargely-populated counties in the US wereidentified, along with any state with ahistorically acknowledged statewide traumasystem. A sample of these communities wascontacted. Trauma stakeholders in SanDiego were also asked which communitiesoutside of San Diego were best practicetrauma systems. All of the communitiesidentified were contacted.

The surveyed regions were:

§ Contra Costa County, CA§ Los Angeles County, CA§ Orange County, CA§ Santa Clara County, CA§ State of Florida§ State of Maryland§ State of Oregon§ State of Washington

Other communities that were contacted butdid not respond included Alameda County,CA, Dallas County, TX, Philadelphia County,PA, and the State of Arizona. AlamedaCounty has a better practice funding sourcein the form of a trauma tax district that isfully described in the funding section of thisreport.

For purposes of this survey, a trauma systemwas defined as a system of trauma centersand their support components includingprehospital, prevention, system monitoringand financing. Key leadership or stakehold-ers within each system were identified andinterviewed. Using a formal script, theinterviewees were asked to identify better orbest practices using an outline of trauma

system components from the HRSA ModelTrauma System Plan.

The working definition of better or bestpractices was: “trauma system compo-nents or activities that represent innova-tive or effective practices such that thetrauma system is better served because ofthe component or activity”. Theinterviewees were told that to meet thetest of best practice for this survey, thecomponent or practice should be somethingan objective observer would report shouldbe shared as a model for other communi-ties. (For example, some communitiesmight describe their trauma registry as beinga best practice because of the extensivenessof the database, its use for looking at qualityoutcomes, the access it gives to trendeddata, and the role of the registry in creatingsystem improvements.)

Interviewees were asked to rate on a scale of1-5 (5 being best) their system’s level ofachievement for each of the components ofa trauma system and then to describe thecharacteristics of the components for whichthey had better or best practices. The ex-amples below were provided by The AbarisGroup for each component, althoughrespondents were encouraged to provideother examples of their own. Theinterviewees were also asked if they hadbetter or best practices not listed in thecategories provided.

§ Leadership Structure (Example: Thereis a leadership structure that providessystem oversight, direction, traumacenter support and the development of atrauma system plan meeting the corecomponents of the Draft ModelTrauma System Plan from HRSA)

§ Triage System (Example: The traumasystem uses defined standards thatidentify trauma patients at risk, assurestheir transport to trauma centers andare periodically reviewed to limit over-triage and assure minimal under-triage)

“The working

definition of better or

best practices was:

‘Trauma system

components or

activities that

represent innovative

or effective practices

such that the trauma

system is better served

because of the

component or

activity.’”


§ EMS Provider Integration (Example:EMS providers are fully integrated intothe trauma system through educationalprograms, collaborative policy develop-ment, quality review systems andparticipation in prevention programs)

§ Definitive and Rehabilitation Care(Example: Trauma center(s) are desig-nated through independent verificationby a lead agency or the American Collegeof Surgeons that hold to, or nearly to,the standards published by the Ameri-can College of Surgeons; transfersystems that assure appropriate casesget transferred to a trauma center;state-of-the-art rehabilitation care)

§ Information Systems (Example: There isa hospital-specific and system-widedatabank that allows for review ofdemand, compliance and quality factors,using state of the art informationtechnology, e.g., a Trauma Registry)

§ Quality Review System (Example: Atrauma system review process assurescomprehensive trauma case review andtrend analysis for optimized patient careat the patient, trauma center and systemlevels)

§ Public Education/Outreach (Example:The trauma system has a formalizedstrategy for public education on injuryprevention that is tied to the epidemiol-ogy of trauma cases and outreach tohealthcare providers about access to thetrauma system)

§ Trauma Research (Example: There areclinical and empirical research commit-ments by the Level I trauma center(s) onone or more of the components of atrauma system)

§ Legislation and System Financing(Example: The trauma system is sup-ported by established legislative authori-zation, empowerment for monitoring

and a stable system for funding traumacenters and system activities thatprovides for appropriate resources toachieve trauma system goals)

Better or best practices in San Diego Countywere also categorized during the inventoryand interview process.

This method for best practice inventorymay have significant limitations. Defini-tions were suggested for each category andtherefore might have led a community to aconclusion of best practice that might nothave been previously considered as such.Also, information collected was self-reported and generally from one individual(considered a lead system stakeholder).Due to limited study resources, the re-spondents’ opinions were not indepen-dently verified. Additionally, surveyedcommunities listed their better/bestpractices as such based on their individualexpectations regarding what would qualifyas a component for the “better” or “best”practice categories. San Diego’s list ofbetter/best practices is a composite of anumber of stakeholder opinions andtherefore faced a more rigorous test.

Results

Ultimately, eight trauma systems weresurveyed and inventoried along with theSan Diego Trauma System. Six surveyedcommunities identified their leadershipstructure as being best practice. Thecommittee structures, multidisciplinaryorientation and the nature of the county/state lead agency were all cited as ex-amples of their best practices. All eightcommunities listed triage as either best orbetter practice. Key to most surveyedcommunities was the periodic updating ofthe criteria and standardization. Florida ispresently reviewing over- and under-triage.There were two best and five better prac-tices identified for the category of EMSprovider integration. Most of these com-munities described prehospital staffinvolved in the policy setting and quality


review process. All eight communitiesdescribed their definitive and rehabilitationcare programs as best practice (5 commu-nities) or better practice (3). Exceeding theAmerican College of Surgeons criteria andcredentialing rehabilitation programs wereexamples mentioned by several communi-ties.

All surveyed communities listed informa-tion systems (IS) as a best (6) or better (2)practice. Key to the information systemscomponent was a statewide or region-wideintegrated registry provided by one soft-ware vendor. Washington State has acomprehensive EMS registry to allowtrauma patient tracking from the fieldthrough definitive care. Quality reviewsystems were rated by six regions asbetter/best practice. Subcommittee casereview or regional reviews were listed bymost. Santa Clara County is developing anoutcome database that also does trending.Public education and outreach were listedby five locations. Washington State haseight regional coordinators assigned tothis responsibility, which is in addition toeach hospital’s requirements in this area.Four regions listed the trauma researchcategory as better/best practice, with otherrespondents stating that they were notknowledgeable about this component oftheir system. There are two Level Is inSanta Clara County with involvement intrauma research. Some of their surgeons,who are on sabbatical, use the time tocomplete additional trauma research.

Five regions rated their legislation andfinance component as better/best practice.Two of these communities provide publicfunds to subsidize the trauma centers. TheState of Washington has a stable statewidefunding source for trauma centers throughvehicle licensing and traffic fine surcharges.Five of the regions listed other better/bestpractices. Los Angeles County mentionedtheir efforts to reimburse private hospitalsfor uncompensated trauma care. Marylandnoted their excellent working relationshipbetween the state and the trauma centers

and their statewide communicationssystem that allows inventorying of re-sources for diversion, etc. Oregon men-tioned the excellent referral pattern be-tween the Level III and IV trauma centers.Santa Clara County noted that they workespecially hard to make the trauma registryrelevant to the local providers and theyissue an annual Trauma System Report.Washington noted their strong regionalnetwork that assures grass root supportand buy-in on policies and planning. BothOregon and Washington have an inclusivesystem, which includes statewide designa-tion of hospitals at one of the levels. Theexception for both states is their singlemetropolitan area (Seattle for Washingtonand Portland for Oregon) where the desig-nation is exclusive to one or two hospitals,respectively.

These practices compare favorably to theSan Diego County trauma system with itsacknowledged best practices in leadership,definitive and rehabilitative care, qualityreview processes, public education andoutreach, and trauma research.

The results of the best practice survey arefurther summarized in the exhibit on thefollowing page.

B

Community/State Leadership Structure

Triage System

EMS Provider Integration

Definitive & Rehabilitation

Care

Information System

Quality Review System

Pubic Education &

Outreach

Trauma Research

Legislation & System

Financing

Other

Contra Costa County, CA ü+ ü ü ü ü+ ü+ ü+ ü+

Florida ü ü ü ü+ ü+

Los Angeles County, CA ü+ ü+ ü ü+ ü ü+ ü+Compensation of private hospitals for indigent care

Maryland ü+ ü+ ü+ ü+ ü+ ü ü+ ü üState

communication system

Orange County, CA ü+ ü+ ü ü+ ü+ ü+ ü ü+

Oregon ü ü+ ü üStrong referral

patterns between IIIs and IVs

Santa Clara County, CA ü ü ü+ ü+ ü+ ü+ ü Annual system report

Washington ü+ ü ü ü+ ü+ ü ü+ ü+ ü+ Regional planning with local buy in

San Diego County, CA ü+ ü+ ü+ ü+ ü+

Trauma System Best Practice SurveyBetter (ü) - Best (ü+) Practice(self-reported by system stakeholders)


III. Special Topics

Trauma Triage

Introduction

The process used to select injured patientsfor transport to trauma centers, otherwisereferred to as trauma triage, is a complexand diversified subject. There are in excessof 220 journal articles published on traumatriage methods and outcomes. The topic ismade more difficult by the fact that whilemost trauma system triage policies in-clude quantitative and qualitative decisionmaking schemes, most contemporarytrauma systems rely heavily on the qualita-tive field assessments of patients relativeto the need for the trauma center.

The Abaris Group’s analysis of trauma triagefor the San Diego County trauma systemused several approaches. First, factualknowledge was gained through a review ofexisting trauma triage documentation. Thiswas supplemented with impressions estab-lished through interviews with system users.Together these formed the basis for TheAbaris Group’s review of the current statusof trauma triage.

This review addressed trauma triage in theSan Diego trauma system from three per-spectives:

§ catchment areas§ triage decision tools§ evaluation of capacity

An additional attempt was made to analyzetrauma triage from trauma registry data andpotential linkages with other databases.Major limitations were evident utilizingthese resources to fully investigate traumatriage. Then, limitations in accessing datafor quantitative analysis resulted in a focuson qualitative approaches for the analysisof the following topic areas:

§ value of assessing over- and under-triage in a trauma system

§ benchmarks in triage decision making§ barriers to analysis of trauma triage§ recommendations to enable analysis of

system triage

Understanding the TriageProcess

Catchment Areas

Catchment area boundaries define whichtrauma center a major trauma patient willlikely be transported to within the San Diegotrauma system. These boundaries existtoday as they were defined in 1984 when thesystem began with only minor changes overthe years. According to the collective histori-cal memory of some senior trauma centerindividuals interviewed, the initial catchmentarea decision process was primarily drivenby the EMS Agency and the trauma centerswith input from the prehospital agencies.Boundary lines were said to have beendrawn based on driving times to the traumacenters, the San Diego City FireDepartment’s Fire Demand Zones, andequity among the trauma centers. Trafficpatterns and roadway access were alsoconsidered.

There is considerable debate by someprehospital agencies on the original zonesand the level of objective care used to definethe zones with a bias that the traumacenters had a strong role in their defini-tion. There has not been a significantreview of trauma catchment areas sincethe beginning of the program.

A San Diego County trauma system policydescribes the catchment areas. There is ageneral boundary map and a multiple-pagestreet-by-street description of the catchmentarea for each trauma center. Children (ages0 - 14) with qualifying injuries or suspicionof risk are triaged to Children’s Hospitalregardless of the location of the incident.The maps and boundary descriptions are

“There has not been a

significant review of

trauma catchment

areas since the

beginning of the

program.”


provided to paramedics in their trainingprograms. A quick reference guide of thetriage criteria is available, but it is rarelyused. Most paramedics interviewed con-firmed that the catchment boundaries werefollowed.

Triage Decision Tools

The San Diego County Trauma System hasutilized a trauma decision tree algorithmto sort major trauma patients from otherinjured patients since implementing thecounty system in 1984. The trauma catch-ment decision scheme is a companiontool. According to trauma program man-agers interviewed, the algorithm had someminor updates in 2000 and was redistrib-uted system-wide to make the triagestandard compatible with the triagerecommendations made in the revisedAmerican College of Surgeons (ACS)Optimal Resources document. The currentalgorithm is similar to the ACS’s decisiontool. The San Diego tool includes pediatricphysiological parameters and calls out theunique use of trauma hospitals as adecision point for classifying patients andmajor trauma. It sorts mechanism ofinjury into two categories. The algorithmdirects taking the trauma patient to “[the]appropriate trauma center” as opposed tothe closest or highest-level trauma center.While transport time to the trauma centeris not directly addressed in the algorithm,it was addressed in developing the traumacatchment areas.

Studies

In September of 2001 a prehospital pro-posal from the City of San Diego requesteda modification to the existing catchmentareas due to a number of inconsistenciesand complexities of following the catch-ment zone descriptions precisely andpragmatically. The proposal was presentedto the San Diego Medical Audit Committee(MAC). An assumption of the proposal wasthat improved trauma center transport

decisions by the City of San Diego wouldresult from modifying existing catchmentareas to be more consistent with freewayaccess and major traffic flow. MAC re-quested the City provide prehospitalimpact data for one year to look at poten-tial changes for the trauma centers. CityEMS staff indicated that because of thelack of current and complete databasesavailable to the City and the lack of com-patibility of the databases (QANet, TraumaRegistry), the City was not able to collectthe data. The proposal has not beenreintroduced.

There have been two studies on triagesince program inception which werementioned earlier in this report. The morerecent study was in 2000, where a TraumaTriage Task Force was formed whichincluded a trauma medical director,trauma nurse manager, pediatric traumamanager, base hospital nurse coordinator,base hospital medical director, two para-medics, the EMS Medical Director andCounty EMS staff. Many documents werereviewed by the task force, including theoriginal current trauma triage policies, theprevious triage guideline entitled “Trau-matic Injury Considerations for EmergencyPersonnel,” the previous Erickson TriageStudy and the American College of Sur-geons Manual (Resources For OptimalCare of the Injured Patient 1999). Addi-tional information utilized was statisticaldata related to trauma triage and traumatransfer from non-trauma centers totrauma centers for reasons of meetingmajor trauma criteria. A CIREN CrashEngineer also participated in the meetings,providing technical expertise on mecha-nism of injury and assessment of vehicledamage as it relates to injury. While acomprehensive review of triage occurredduring this study, it did not deal distinctlywith the issue of over triage.

Evaluation Capacity

Two approaches to identifying the currentstate of trauma triage evaluation capacity

“While a comprehen-

sive review of triage

occurred during this

study, it did not deal

distinctly with the

issue of over triage.”


were considered in The Abaris Group’sreview. They include the current use of thetrauma decision algorithm and the currentability to track triage decision-making atdecision points across the trauma carecontinuum. Data analysis was not possibleas part of the investigation due to the lackof linked databases and the fact that theprehospital patient care report does notrequire or even provide space to indicatethe reason for patients to be transported toa trauma center.

Trauma Decision Algorithm

The Trauma Decision Algorithm is used as abaseline to identify major trauma patientsacross the system. Prehospital providersutilize the tool for screening to identifymajor trauma patients and to determine theneed to contact their trauma base hospitalsfor transport decisions. Mobile IntensiveCare Nurses (MICNs) at trauma basehospitals make the final trauma center triagedecisions based on the same TraumaDecision Tree Algorithm.

Both the algorithm and trauma catchmentdecision scheme are expected to be con-sistently utilized at multiple levels of thesystem (prehospital, trauma base hospital,trauma center, EMS Agency) for prospectiveor retrospective identification of majortrauma patients. However, interviewed EMSprovider agencies indicated that they rarelyrefer to either document directly. Most EMSproviders indicated that they use their“experience” in determining trauma basehospital contact and in fact they tend to errin favor of sending the injured patient tothe trauma center rather than a one-to-onematch to the criteria. There is also astatement in the triage standard thatstates “When in doubt, take patient toappropriate trauma center.”

The prehospital “experience” criteriamethod is particularly true for the “mecha-nism only” or “when in doubt” criteria. Inaddition, the criteria are considered byEMS field providers, and a majority of

other system stakeholders, as very permis-sive.

Prehospital staff reported variation amongtrauma base hospital staff in selectingpatients for triage, EMS field personnelexpressed frustration regarding the factthat the base hospital staff (not the pre-hospital staff) make the triage decisionand these decision makers may not be partof the trauma team and therefore notavailable to explain the reason for triage.

Trauma centers activate various levels oftrauma team response based on patientsmeeting the algorithm criteria. Some hospi-tals have customized criteria for traumateam or trauma consult activations.Children’s Hospital, for example, hascustomized criteria used internally to meetthe specific needs of injured children. Thereis some inconsistency among hospitalsregarding trauma registry entries. Sometrauma centers enter all trauma patientstriaged to the trauma center and some enteronly patients meeting the more limitedCounty definition for major trauma.

Tracking Triage Decisions

A primary source for tracking trauma triagedecisions is usually the prehospital patientcare data collection form. Medical incidentreporting in San Diego County for theprehospital side of the system includes bothcomputer and paper reporting. QANet iscomputer-based and used by the majority ofprehospital agencies. The City of San Diegodoes not use QANet but rather a paperbubble form that requires scanning. This isdue to their belief that there are qualitycontrol problems with the system and thefact that it also is difficult to get reportsfrom the system, and the reports providedare out of date. The City has initiated aredundant Pocket PC patient documenta-tion system as well. San Diego City’s callvolume represents a major portion of thetotal EMS calls in the county.


While it is the MICNs responsibility tomake the official triage decision, neitherthe bubble form nor the QANet have datafields that ask the medic to identify whattriage criteria element was used to deter-mine if the patient was a major trauma.Bubble form scanning for those agenciesnot using the QANet is reportedly 18months behind at the EMS Agency, makinginvestigation of the current triage practicevery difficult.

The MICNs are the intermediary in thetriage decision making process. They makethe final decision for transport to a traumacenter. All trauma medic reports are com-municated through the MICN. The MICNutilizes the QANet to enter patient careinformation from the radio report. Physi-ological, anatomical, mechanism and otherdata is entered. As with medic reporting, theMICN does not identify the triage criteriaused to classify the patient as a majortrauma. Variation among MICNs andhospitals with regard to data input has notbeen established. Determining the appro-priateness of the triage decision atprehospital, MICN, and trauma servicedecision points is therefore problematic.As mentioned, the actual reason fortransporting a patient to a trauma center isnot documented and there is no linkeddatabase to track decision to outcome.This makes evaluating the incrementalimpact of triage decisions impossible on asystem-wide basis. Similarly, it makesdetermining where in the continuum thesystem can be improved difficult at best.

Trauma registries at the hospital and Countylevels do not include sufficient or consis-tently completed patient data from field carethrough discharge. Finally, there are nofields in the trauma registry at either theprehospital or hospital levels that specificallyidentify what element or elements of thetriage decision tree algorithm resulted in thetriage decision made by medics, by the

MICN for field triage, or by the traumaservice for internal triage.

Value of Assessing TraumaTriage

Appropriate triage is a major factor inoptimal patient outcomes as well as theoptimal design and financial stability of atrauma system. The concept of triage isbest described as the process by which the“right patient gets to the right hospital atthe right time.” The goal of a contempo-rary trauma system is to limit over- andunder-triage. Over-triage is generallydefined as those patients that did not needthe services of a trauma center, usuallytranslated as those patients triaged to atrauma center but sent home from the ED.Under-triage includes high risk patientsthat are transported to a non-traumacenter or that go unrecognized as a highrisk patient at a trauma center. It is gener-ally accepted in the literature that a level ofover-triage must occur in order to capturethose patients with less obvious, butpotentially life-threatening, injury. Acommonly quoted over-triage rate is 20percent. There is however a collection ofarticles that argue that up to 35 percentover-triage is necessary to achieve as littleas a 1 percent under-triage rate.

Using the ED discharge definition for“over triage”, there is considerable varia-tion in the over-triage rate in San Diegotrauma centers. San Diego trauma centershave over-triage rates ranging from 0 to 48percent. The individual rate of traumapatients not admitted as inpatients for thesix San Diego trauma centers (January2002 to September 2002) were as follows(in percentage order): 0, 8, 21, 34, 43 and48 percent. Most of the patients weredischarged home from the ED while asmall number of these patients died orwere transferred.

The zero percent at one trauma center isas a result of a policy by that trauma centerto “admit” all patients to their trauma

“Finally, there are no

fields in the trauma

registry at either the

prehospital or hospital

levels that specifically

identify what element

or elements of the

triage decision tree

algorithm resulted in

the triage decision

made by medics, by

the MICN for field

triage, or by the

trauma service for

internal triage. “


service for at least an eight-hour periodregardless of the outcome of the initialassessment. This is an uncommon proce-dure and it is unclear whether their par-ticular patient profile is different fromother trauma centers as the arrivals byambulance are all in theory dictated by thesame triage standards countywide.

It is difficult to compare data using thisdefinition of “over triage” from individualtrauma centers without more detail. Forexample, one hospital may admit atrauma patient for several hours andclassifies the patient as an “ED discharge”and another that may “admit” a patient forthe same number of hours and classify thepatient as an “inpatient admission”.

Over-triage results in patients with onlyminor injuries being transported to higherlevel trauma centers rather than moreappropriate facilities. It is understood thatover-triage can overtax the trauma system,resulting in excessive resource use andpotentially wasted trauma resources.Under-triage may create a situation wherepatients are put at risk by treatment at afacility not adequately equipped for traumaor where time is wasted in transferringthese patients to a higher-level traumafacility.

Discussions with the San Diego traumacenters indicate a widespread belief that thetrauma system has a clinically acceptableover-triage rate and is able to handle theresource needs of over-triage. Under-triageis believed to be minimal. There is a strongperception by the trauma centers that anin-depth quantitative analysis requiringchanges in data sources is not needed. Ashas been previously described, there havebeen two studies of the triage systemsince system inception, but neither ofthese studies meet the rigorous test of amethodical triage review that is the stan-dard for literature reporting. A compre-

hensive study of the impact on outcomesand resource consumption of the triagecriteria and the actual application of thecriteria has not been conducted in the SanDiego trauma system.

The recent work and direction of thePhysician Variation Study, described in thespecial studies section of this report,reinforces that the system is supportive oftriaging additional patients directly totrauma centers. However, the perceptionby most EMS providers and many non-trauma center stakeholders is that theover-triage problem is significant and inneed of revision.

Triage Benchmarks

A comprehensive quantitative analysis ofsystem over- and/or under-triage enables anassessment of the efficacy of the triagecriteria currently used and identification ofspecific issues relative to triage decisionmaking, and may potentially be used toprovide information useful for resourceallocation decisions. There are a number ofstudies that provide benchmarks for triageanalysis design.

Acceptable triage rates depend on thesystem goals and objectives as well as theimpact on patient care and financial stability.Over-triage acceptance may be based onresource level and change with time.

Changes in triage criteria and their directimpact on those rates are evidenced inseveral studies investigating the role ofmechanism of injury alone as the triageguideline. An example of using analysis tofurther improve triage standards is clearlydefined in the 1986 Orange County (CA)study.23 In that study, the initial rate ofover-triage was reported at 18 percent.During a one-year period with only physi-ologic criteria used, 21 percent of the non-central nervous system motor vehicle

23 Baldwin, L C., M A. Murdock, and J G. West. A Method for Evaluating Field Triage Criteria.” JTrauma 26 (1986): L655-9.

“A comprehensive

study of the impact on

outcomes and re-

source consumption

of the triage criteria

and the actual

application of the

criteria has not been

conducted in the San

Diego trauma

system.”


trauma deaths occurred in non-designatedhospitals. The criteria were modified tomake them more sensitive (anatomicaland mechanism criteria were added) anddeaths fell to 4.4 percent, but the rate ofover-triage nearly doubled to 40 percent.The study goes on to indicate that adjust-ing triage criteria must include an appro-priate balance and system users mustmake that determination.

An Oregon study using injury mechanismalone as a triage criterion resulted in anover-triage rate of 14-43 percent dependingon whether all patients or only thosemeeting clinical criteria were included inthe computation. Using trauma scorealone would have resulted in 8-36 percentof seriously injured patients beingmissed.24 The study, which was limited bythe number of patients (631) and thelength of time (3-months), demonstratedthe trade-off between over- and under-triage as triage criteria are changed.

It is important for trauma systems to ensurethat the designated trauma centers continueto see a high volume of seriously injuredpatients.25 Trauma systems were developednot only to provide treatment for the mostseriously injured, but also for those with the“potential” for serious injury – the “mecha-nism of injury only” patients.

Quantitative analysis of triage can alsoprovide documentation of financial factorsimpacting the trauma and EMS system. Thefinancial impact on non-trauma facilitiesbypassed as a result of triage criteria fortransport of seriously injured trauma pa-tients to trauma centers is sometimes usedas a reason for nonparticipation in atrauma system. One North Carolina triagestudy demonstrated that those seriously

injured patients treated in the rural facili-ties incurred increased LOS, hospitalcharges, and risk of dying as the injuryseverity level increased, but reimburse-ment changed little. The article encour-aged the rural facilities to be full partici-pants in the trauma system and supportcriteria that moved the seriously injured tothe regional Trauma Center.26

A common, and increasingly important,issue in trauma system participationinvolves uncompensated care. Insurancestatus may affect whether a trauma patientfirst seen in a non-trauma facility is subse-quently transferred to a trauma facility. Asimilar analysis of triage and transferpractices in Washington State concludedthat insurance status was indeed anindependent predictor of transfer, withthose patients having commercial insur-ance remaining in the initial admittinghospital.27 These and other results ofquantitative analysis may be used by thetrauma system in supporting issuesrelated to disproportionate reimbursementstrategies.

Analysis of under-triage is critical becauseof the potential impact on patient care andoutcomes. Not only is there a risk of in-creased mortality from under-triage, but alsofrom complications and the resulting qualityof life. A recent study in San Diego useddata from four trauma centers and reporteda rate of 10.1 percent in major in-hospitalcomplications among trauma patients.28

While the purpose of the study was to lookat functional outcomes for these patientspost-discharge, it can reasonably be arguedthat since these patients were treated intrauma centers following ACS guidelinesand best practices, the rate of complica-

24 Lowe D K, Oh GR, Neely KW, Peterson CG. Evaluation of Injury Mechanism as a Criterion in Trauma Triage. American Journal of Surgery 152 (1): 6-10, 198625 Cooper, M, Yarbrough, D, Zone-Smith, L, Byrne, K, Norcross, D. Application of Field Triage Guidelines by Prehospital Personnel: Is Mechanism of Injury a Valid Guideline for Patient Triage? Am Surg 1995 Apr;61(4):363-7.26 Rutledge R. Shaffer VD, Ridky J. Trauma Care Reimbursement in Rural Hospitals:Implications for Triage and Trauma System Design” J of Trauma, 40(6): 1002-8, 1996 June.27 Nathens AB, Maier RV, Copass MK, Jurkovich GJ. Payer Status: The Unspoken Triage Criterion, J of Trauma 50(5): 776-83, 2001 May.28 Holbrook TL, Hoyt DB, Anderson JP. The Impact of Major In-Hospital Complications on Functional Outcome and Quality of Life After Trauma, J of Trauma.

50(1): 91-95, 2001 Jan.


tions may be significantly higher for thesepatients if they were treated in non-traumafacilities. The study did conclude thatmajor in-hospital complications contrib-uted negatively to quality of life. Quality oflife is seldom studied when triage criteriaare evaluated.

Identifying those patients most at risk forover/under-triage may assist in the decisionmaking process relative to a quantitativeanalysis for the San Diego trauma system.Using ACS criteria, literature indicates thatmost trauma patients at risk for under-triage are primarily older female patientsand those less likely to have multisysteminjuries. Rates of under-triage in theliterature range from 20-30 percent (Or-egon, 21.9 percent). Among those over-triaged, patients with head or face injury,intoxication, and obesity were over-repre-sented. Reported over-triage rates areconsiderably higher than under-triage withmost reporting over-triage rates of wellover 25 percent.

Of note, the Los Angeles County EMSAgency conducted a comparison of thedifferent triage criteria used throughoutCalifornia. This exhibit can be found inAppendix E.

Barriers for Analysis

Several limitations related to triage analysishave been mentioned in this report. Addi-tional investigation confirmed the difficultyin completing a quantitative analysis oftriage in San Diego County. Specifically,these issues included:

(1) Patient Definition. There are significantlimitations to the patient definitionsused in current San Diego data sources(QANet, the Trauma Registry, andhospital discharge data). Cases in-cluded in the Trauma Registry aredeaths, all transfers in or out, hospital

admissions greater than 24 hours, andadmissions to an intermediate orintensive care unit. These do notinclude all of the patients meeting thetrauma decision algorithm. The QANetprovides information on all prehospitaltrauma transports. Hospital dischargedata which could be used to lookspecifically at under-triage includes allpatients admitted to the hospital butexcludes ED treat and release casesand prehospital deaths.

(2) Linked Databases. There is no currentability to link data from dispatchthrough prehospital providers includ-ing the QANet to the limited data setincluded in the Trauma Registry and toother more inclusive trauma patientdata sets (e.g. California PatientDischarge Dataset). Although theprinted data dictionary informationindicates that the QANet run numberis included on both the QANet andTrauma Registry databases, it isapparently not currently used. Thereare plans to have an automatic down-load of prehospital data to the traumaregistry.

(3) Triage Decision Points. The decision-making process at points along thecontinuum of care cannot be verified asno documentation of criteria used tomake the triage decision is available.Timing of the availability of informa-tion from some of the data sourcesresults in an inability to provide cur-rent data (e.g. the EMS Agency bubbleform scanning is 18 months behind).The two trauma registry systems(Cales and Dales) cannot share datarelative to outcomes. The ISS, RTS,and probability of survival are notsaved when this information is trans-mitted for one of the registries. Thissituation is currently being addressedthrough other efforts.

29 Kilberg L. Clemmer TP. Clawson J. Woolley FR, Thomas F. Oreme JF Jr. “Effectiveness of implementing a Trauma Triage System on Outcome: A ProspectiveEvaluation, J of Trauma. 28(10): 1493-1498, 1988 Oct.


There are a variety of methods to conductsuch a study in San Diego:

(1) Analysis of Triage to Outcome. As earlyas 1988, Fresno County, CA used thisapproach in a study of triage guide-lines with the objective of identifyingthe optimal combination of physi-ologic (using the Trauma Score),anatomic, and mechanism of injurycriteria for correctly identifying themost critically injured patients withoutcreating an unacceptable level of over-triage.29 The study provided informa-tion prospectively on all patientstransported by the EMS system asopposed to other studies which onlylooked at those transported to traumafacilities. In addition, they collectedinformation on all patients, not justthose admitted to a facility, and usedmultiple sources to obtain the mostcomplete and accurate data possible.While the study had a relatively smallnumber of patients, the results ob-tained provided not only informationon balancing the over/under-triagepopulation through specific guidelines,but more importantly provided amethodology for system-specificanalysis in order to refine protocolsrelative to triage.30

The major benefit of this approach isthat it would allow an examination ofprehospital events to evaluate if triagecriteria are consistently followed, as wellas the ability to measure both over- andunder-triage (this would require that allcalls go through QANet, not just thosecalls to a trauma base hospital). If it ispossible only to link the data to theTrauma Registry then only over-triagecould be analyzed since patients notentered into the Trauma Registry wouldbe excluded or individual patients thatwent to non-trauma centers would not

be studied. If non trauma centerscould be encouraged to participate inthe study or the QANet data could belinked with the California PatientDischarge Dataset, then both over/under-triage could be analyzed.

(2) Retrospective Analysis of CaliforniaPatient Discharge Data and VitalStatistics. San Diego could use theCalifornia Patient Discharge Data setcontaining multiple IDC-9 codes tocompute an ISS that could be used asthe “gold standard” for calculating thesensitivity and specificity of the sys-tem. Calculations can be accomplishedwith commonly available softwareprograms (ICD-Map). In taking thisapproach, consideration should begiven to whether enough ICD-9 diag-nostic codes are available to computean ISS along with variables describingthe patient and facility. This approachwill be useful in obtaining a broadoverview of both over- and under-triage. Using this method, over-triagecan be calculated as has been done inother studies. Patients who were seenin the ED and admitted to the hospitalpossibly for co-morbid conditions willimpact the resulting rate. Excludedfrom these calculations are those whowere at risk for severe injury due tomechanism, but were evaluated by anexpert (trauma surgeon) and deter-mined to not have these injuries.

Limitations of the use of population-based data sources, primarily hospitaldischarge data and vital statistics deathdata, in assessing effectiveness oftrauma triage have been documented toinclude:

§ Incomplete data capture, forexample, missing those casestreated and released withoutadmission to the hospital, cases

30 Knopp R, Yanagi A, Kellsen G, Geidi A, Doehring L. Mechanism of Injury and Anatomic Injury as Criteria for Prehospital Trauma Triage, A of Emerg Medicine .17(9): 55-62. 1988 Sep.


where death occurred after dis-charge but was primarily due to thetrauma, and patients treated infederal facilities such as those onreservations or at military hospitals

§ Coding issues relative to proce-dures and diagnoses when the datais designed for other purposes

§ Lack of understanding of the datasource on the part of investigatorsnot familiar with the collectionprotocols and procedures as well aslevel of errors allowed. This limita-tion is not restricted to the Califor-nia Patient Discharge Data sets.

Please refer to the additional discus-sion of population-based trauma studyin the Data Analysis section of thisreport.

(3) Retrospective Analysis of TraumaRegistry Data. A number of studieshave been completed using a retro-spective trauma registry data review.One study involved investigatingseriously injured patients who werefirst treated in rural hospitals. Whilenot focused on triage guidelines perse, this study used registry data fromOregon and Washington to investigatethe role of Level III, IV, and V desig-nated trauma centers.31

The Florida Trauma Triage Study alsoused trauma registry data and publishedmethods and results of their studyincluding evaluations specifically fo-cused on pediatric and geriatrictrauma.32 This approach is often themost tempting because it representsmore readily available and understooddata. However, using registry data alonerestricts the ability to explore issues ofunder-triage since patients never

triaged to a system facility, or thoseseen but not admitted for a period oftime, are not included.

(4) Facility-Specific Analysis of ED Data.This approach was discussed in a 2002article that examined changes in triageguidelines relative to attending responsein the ED as proposed by the ACSCommittee on Trauma (ACSCOT). The1999 guidelines, while limiting under-triage, result in potentially significantover-triage. The ACSCOT-amendedguidelines for defining major traumaresuscitation are (1) confirmed SBP <90 mm Hg at any time in adults, andage-specific hypotension in children,(2) respiratory compromise/obstruc-tion and/or intubation, (3) GCS score<8 with mechanism attributed totrauma, (4) gunshot wounds to theabdomen, neck, or chest, (5) transferpatients from other hospitals receivingblood to maintain vital signs, and (6)emergency physician’s discretion.While the results of this study wereinconclusive regarding the role oftrauma surgeon arrival time, they didsubstantiate the first four criteria aspredictive of the most seriously injuredpatients whether measured by ISS,mortality rate, LOS, or higher numberof ICU days.33 This approach, if appliedonly to specified facilities, would notallow system-wide analysis, but couldbe adapted with individual facilitiessubmitting only specified elements foranalysis. This would be primarily usefulfor studies related to triage criteriaefficacy.

31 Mullins, R J Mann, N C, Hedges, J R, Wortall M H, Zechnich, A D, Jurkovich, GJ. Adequacy of Hospital Discharge Status as a Measure of Outcome AmongInjured Patients JAMA 1998:279:1727-1731.

32 Phillips S, Rond, P C III, Kelly, S M, Swartz PD. The Need for Pediatric-Trauma Specific Triage Criteria: Results from the Florida Trauma Triage Study, PediatricEmergency Care. 12(6): 394-9, 1996 Dec.

Phillips S, Rond P C III, Kelly, S M, Swartz, P D. The Failure of Triage Criteria to Identify Geriatric Patients with Trauma: Results From the Florida Trauma TriageStudy, J of Trauma. 40(2): 278-83, 1996 Feb.

33 Tinkoff G H, O’Connor R E, Validation of New Trauma Triage Rules for Trauma Attending Response to the Emergency Department, J of Trauma. 52 (6): 1153-1159,2002 June.


Trauma Registry

Overview

An assessment was made of the San Diegotrauma registry. Interviews were conductedwith both of the proprietary owners of thetwo trauma registries utilized in the SanDiego Trauma System. Dale Fortlage, withthe firm Intelligent Software Solutions,implemented the original San Diegotrauma registry 18 years ago. Thisregistry’s official name is The San DiegoTrauma Registry but is commonly referredto (as it is in this report) as The DalesRegistry. Rick Cales designed and imple-mented the registry known as TRAUMA!,approximately 19 years ago. The CalesRegistry is new to the San Diego traumasystem as of 2000. Two of the six traumacenters are currently utilizing the CalesRegistry, Scripps Mercy and Children’sHospital.

Registry Specifics

Dales Registry operates in the DOS operat-ing system and has approximately 20standard reports. These reports are utilizedpredominately for the medical audit reviewprocess both within the trauma center andthe system review at MAC. It has thecapacity to generate additional reports butmust be converted into software such asExcel or FoxPro in order to manipulate thedata. If the facility has information systemstaff available, this is an easy task. If theydo not, they can contract by the hour andDale will generate the reports. Dale Fort-lage indicated that he is probably calledabout a dozen times a year to supportvarious trauma centers in generatingspecial reports.

The Dales Registry is able to support somecalculations, such as the probability ofsurvival, and converting the abbreviatedinjury score (AIS) to an Injury Severity Score(ISS). It prints this information in a sum-mary report used for MAC but the program

cannot write the results to a file. Thus, thecalculations are not saved when the dataare transmitted to the County. The EMSAgency is working on a program that willcalculate and retain the ISS, RTS (revisedtrauma score), and the probability ofsurvival from Dales Registry, based upon aprogram written by Cales. This will allowfor the comparison of data from bothregistries to assess clinical outcomes.

Three of the four trauma centers that useDales Registry transmit the data to theCounty by e-mail. Palomar Medical Centersubmits their registry data by disk. Bothtrauma centers utilizing the Cales Registrysubmit their trauma data monthly by disk.Approximately 250 data points can becollected by the trauma center with only 150data points provided to the County. Theother data is considered confidential andutilized as part of the peer review process atthe individual trauma center. The list ofcomplications is provided to the County butthe internal review and corrective actionstaken are not submitted.

There has been an expressed desire by someof the trauma centers using the DalesRegistry to be able to link to the hospitalmainframe. This would allow for the seam-less transfer of financial data and basicdemographic information, reducing theirdata input time by as much as 30 percent.The Dales Registry does not have plans toprovide this linkage.

The Cales Registry operates in Windowsand is built on a relational database asopposed to a flat file system. There areapproximately 50 standard reports that canbe generated by the trauma programmanager at their facility. Additionally, theyare able to query an endless amount of adhoc reports whenever needed for specialstudies. Most reports have the capacity tobe generated in both a narrative andgraphic format. Cales has produced anidentical summary report like the one usedby all the trauma centers to complete theQA review for MAC. A comparison was


made of the data dictionary used in theDales Registry and all data elementsappear to be reconciled by Cales to createuniformity of the two programs.

Both registries will soon be an interfaceprogram where the data will be uploadedbetween the QANet and both registriesand be used to upload the prehospitaldata into the trauma registries.

In 1999 there was an expressed desire onthe part of the trauma program managersto evaluate other trauma registries. A“Registry Fair” was held, with vendorsrepresenting TRACS, Collector, CalesTrauma!, and the Dales Registry. Thegroup did not make a unanimous deci-sion. Some had concerns about moving toa Windows-based platform and possiblyhaving limited access to past data thatwas in a DOS format. The trauma programmanager at Scripps Mercy had priorexperience working with Cales Registryand supported moving to the Windowsformat. They had a representative of theirInformation Services Department attendthe vendor fair and they supported thedecision by Scripps Mercy to change tothe Cales Registry. Children’s Hospitalalso selected the Cales Registry. The twofacilities started utilizing the new Win-dows-based registry in January 2000. Theother four facilities remained on the DOS-based Dales registry. There was someinterest expressed at the time to considerutilizing TRACS, which was developed bythe ACS. However, it was not selected asit was in beta testing and needed morerefinement.

Basically, the data is collected at thetrauma centers and the County receivesdata with patients that meet globalcriteria and then the County screens thedata that meets inclusion criteria. Not allhospitals provide their complete traumaregistry data base to the County and thereis a difference of opinion between the

trauma centers on the publication by theCounty of that data by individual hospitalor for trending. While the County has fairlyrobust resources and an in-depth traumainformation system, the direct or indirectlimitations on data reporting and trendingartificially confines the use of the fullresource potential.

San Diego County Registry

Since January 2000, the EMS Agency hasreceived trauma data from two differentregistries. They utilize the same criteria indefining the cases to be downloaded to theagency; all deaths, all transfers in or out,all hospital admissions greater then 24hours, and all admissions to an intermedi-ate or intensive care unit. Initially the EMSAgency had difficulty compiling the datainto a single reporting structure and had torun parallel reporting methodologies. Thiscaused a delay in generating their annualreport. They have worked out a number ofthe conflicts that existed in comparing thetwo registries but it still takes a significantamount of County work and cost to makethe data compatible. This is staff time thatcould be used for other initiatives fortrauma and the EMS system. There clearlywould be real time savings and costbenefit in having all providers using thesame registry.

There are other significant delays with theCounty registry portion of the registry interms of reporting results. There is a built-in delay of data sent from the traumacenters (3 month lag), significant timetaken to rectify missing data, and thetrauma centers have historically requiredthe county to share data tables beforereporting. These built in inefficiencies addsignificant time delays to the County’sreporting functions.

“While the County

has fairly robust

resources and an in-

depth trauma infor-

mation system, the

direct or indirect

limitations on data

trending and reporting

artificially confines

the use of the re-

source potential. “


The County is planning on a quarterlyabbreviated report which would reflect theprevious quarter’s activities.

Analysis of the San DiegoTrauma Registry

The Abaris Group conducted interviewswith the six San Diego trauma centers andthe County EMS Agency staff. Based onthese interviews and our expertise, thestrengths, weaknesses and opportunitiesfor the two programs were identified.

Strengths

Dales Registry

Dale’s registry is a known commodity andhas been in existence for approximately 18years. The users are familiar with itsoperation and how to produce the standardreports they need for QA reporting. Withthe exception of County staff time, there isminimal cost as the product has been paidfor and the only charge generated is whenthe user needs assistance in producingspecial reports. The existing registrycontains approximately 20 standardreports. Moving the data into Excel or FoxPro provides ad hoc or queried reports. Itwas expressed by some trauma programmanagers that they favor the Dales Regis-try because the current MAC review pro-cess has been built upon the reportsgenerated by this registry. They believe it isa quality product and that because Dale islocated in San Diego, he is able to servicetheir needs and they are able to trend theirdata. The trauma program managers havevoiced concerns about not being able tolook at old data for trending if they moveto a new Windows-based registry.

Cales Registry (Trauma!)

Cales Registry is written in Windows andhas a relational database, which allows for

calculation and retention of the RTS, ISS,and the Probability of Survival. The pro-gram has the capabilities previouslymentioned. Cales has produced a Sum-mary Report like the one used by the DalesRegistry for the MAC review process. Hehas also reconciled his data dictionary tomatch that of the Dales Registry.

The Cales Registry can be linked to otherdatabases, making it possible to link to datacollection systems within the trauma center.This allows for direct input of demographicand financial data into the registry, reduc-ing the time it takes to enter a trauma caseby thirty percent. It has the ability to linkto the National Trauma Data Bank, allow-ing the individual trauma center to bench-mark their performance against othertrauma centers.

Technical support is provided by resourcestaff, located on the West Coast, and isavailable Monday through Friday duringbusiness hours.

Weaknesses

Dales Registry

The registry is written to work in theoutdated DOS operating system, whichhas a number of limitations including itslack of ability to write calculations to anelectronic file. The program can runcalculations like the probability of survival,but it cannot save the output to an elec-tronic file. The San Diego County EMSAgency is attempting to resolve this issuebut this resolution will not deal with themultitude of other limitations of a DOS-based program.

The Dales Registry does not link easilywith other databases and it only producestabular data. Graphic reports can only begenerated when data is exported into other


software. There are no plans to move theproduct into a Windows-based platform. AWindows-based platform would elevatemany of the issues listed in this report.

Cales Registry

Cales’ Windows version is a newer pro-gram and has a long history of new ver-sions to improve functions, but whichcreate additional learning needs. Thetechnical support, although available, isnot the same as the hands-on supportreceived from the Dales Registry. As a newregistry, there is the cost of purchase,training and maintenance, which do notoccur with the existing Dales Registry.

Both Registries

Neither registry in the present format hasthe ability to make inquiries nor conducttrend analysis. There are also major limita-tions placed on the county relative to look-ing at system and center outcomes orcomplications even at the trended level.

Opportunities for Improvement

Most trauma program managers identifiedthat there is an under-utilization of thedata collected both at the facility andCounty levels.

Those using Dales Registry have difficultycreating ad-hoc reports unless they haveknowledge of Excel or FoxPro to manipulatethe data and create query structures. Thosethat did not have the knowledge felt theywere probably under-utilizing the registry’scapabilities. There was strong support fromthe users of Cales Registry that they couldcreate any ad hoc report they wanted when-ever they wanted, without needing directsupport from the Cales technical staff.

There was an identified need to expectmore reporting from the San Diego CountyEMS staff. Most trauma centers would likesystem reports from the County at the MAC

meetings. It would be beneficial to know ifwhat they are seeing at their facility is asystem-wide occurrence (e.g. a decrease inhead injuries or increase in a specificinjury, etc.). County staff would be willingto support this, if they received specificrequests or clarification of expectedreporting.

Improved Security

There is an opportunity to improve thesecurity and handling of data submitted tothe San Diego County EMS Agency. Mosttrauma program managers also felt thereshould be a sign off of receipt of the traumadata when provided on disk and for the Pre-MAC binder. This would create an account-ability trail and validate their submission ofthe data. It was suggested that a reaffirma-tion by the San Diego County EMS Agencybe written as to how and where the dataare stored, who has access and how it isutilized.

Data from some trauma centers is stillsent by e-mail to the County. The Countyquestions the security of registry datasubmitted by e-mail. There should besome documentation of how this data isencrypted to prevent unwanted access.

Other Trauma Registries

Over the past two decades there have beenat least 20 trauma registry vendors. Sophisti-cation, user friendliness and vendor prefer-ences have all permeated the decisionprocess of selecting a trauma registryvendor. Interest in registry vendors haswaxed and waned and many of the earlyvendors are no longer in business. TheAbaris Group obtained information oncurrent registries used around the country.Registries evaluated included:

§ Trauma One by Lancet Technology –being used in LA County

§ National TRACS by ACS – being used inNorth Carolina & Tennessee

Trauma Registry Name: Collector Dales Trauma! Trauma Base Trauma One TRACSWashington

Trauma RegistryFeatures: Program Initiated 1989 1987 1986 1986 1987 1992 1986 Windows Based Platform Y N Y Y Y Y Y Relational Database Y Y Y Y Y Y Y Data Conversion From Previous System Y Y Y Y Y N Y Stand-alone or Network Functionality Y Stand Alone Only Y Y Y Y Y Supports Single Hospital, County or Statewide System Y Y(1) Y Y Y Y Y Number of Standardized Reports 25 20 50 65 75 50 25 Easy To Use, Customizable Reports Y Y(2) Y Y Y Y Y Import Interface Capability Y Y(2) Y Y Y Y Y Automated ICD-9 Coding, AIS90 and ISS scoring Y ISS Only Y Y Y Y Y Multiple Location Record Access Y Y Y Y Y Y Y Trend QI and Complications Y Y Y Y Y Y Y Training and Education Y Y Y Y Y Y Y Technical Support Y Y Y Y Y Y Y Data Entry by Internet or PDA Y N N Y Y N Y Generates Letter Y N N Y Y N YCost/Pricing(3): Central Site (System) 6,000$ None 30,000$ Variable 7,000$ 3,000$ 6,000$ Individual Hospital 5,000$ 2,500$ 7,500$ 6,000$ 5,000$ 2,000$ Pd by EMS Central Site Maintenance (annual charge) 2,500$ No Charge 20% 1,500$ 5,000$ 2,500$ 2,500$ Hospital Maintenance (annual charge) 2,000$ No Charge 20% 1,500$ 1,200$ 1,500$ Pd by EMS

(3) Pricing varies significantly for all vendors, depending upon how many hospitals are involved and level of product purchased.

Trauma Registry Comparison

(1) Dales Registry has a qualified "Yes" for these items as the system has the capacity to do the activity but it is either not well tested or utilized by all users of the registry.(2) Supports single hospital or County, but not statewide.


§ Collector by Digital Innovations –being used in Pennsylvania

§ Trauma Base by Clinical Data Manage-ment – being used in Ohio

§ Washington State Trauma Registry

The following exhibit reflects the systemcapabilities for the registries evaluatedwhich includes the Cales and Dales Regis-tries. The pricing information is an estimatesince there are many factors that go into acontract bid which provide for discountsbased on the number of units purchasedand features included with each product.There are clearly limitations to any soft-ware program. This exhibit of traumaregistries suggests that some registrieshave additional functionality when com-pared to the two used in San Diego, butagain this is location-sensitive. Thisanalysis and the comparison table shouldprovide some guidance in analyzing whatalternatives are available from a perfor-mance and cost standpoint.

Other Studies

It should be noted that the WashingtonState Trauma Registry recently convertedtheir entire state to Collector. Until threeyears ago they had a number of registriesutilized within their system. At that time,the state purchased the licenses to useCollector as their state registry. Theyprovide the registry free of charge to all oftheir trauma facilities (85 hospitals) andthey provide the training, doing a signifi-cant portion of the troubleshooting beforea user can go directly to Collector toresolve an issue. They stated that nosystem was perfect but after much evalua-tion they felt Collector would best meettheir needs. They have five levels of traumacenters including two clinics in rural areas.The decision to change registries requireda huge commitment for training andeducation on the part of the state, but theybelieve it was well worth the effort.

The State of Oregon uses an in-housedeveloped product and has since the

inception of their trauma system in themid 1980s. Both Oregon and WashingtonState officials and others described in thebest practice section of this reportemphasized the importance of oneintegrated trauma registry softwaresystem.


Injury Prevention

The Abaris Group undertook a study ofinjury prevention efforts in San Diego as acomponent of the study of the overalltrauma system assessment. An inventorywas conducted of the various injury preven-tion programs, identifying the epidemiologyof injured patients seen at the traumacenters.

According to the Centers for DiseaseControl and Prevention, unintentionalinjuries are the fifth leading cause of death,exceeded only by heart disease, cancer,stroke, and chronic lower respiratorydisease. Injury-related (fatal and nonfatal)visits to the emergency department (ED)increased 7.5 percent from 1999 to 2000,growing at a faster rate than all ED visitscombined.

Unintentional injuries and deaths areultimately avoidable, and there are a diversenumber of injury prevention programsdedicated to reducing these occurrences. Asprevention programs are implemented,there is an expectation that the number andseverity of injuries will decline. A Journalof Trauma article published in January 2003demonstrated that even dramatic improve-ment in clinical trauma care would onlyreduce trauma mortality by 13 percent. Yetover 50 percent of the deaths in the studywere potentially preventable with pre-injurybehavioral changes.34 Another study demon-strated that while trauma centers andsystems do reduce pediatric mortality, injuryprevention has far greater potential impacton future pediatric injury outcomes35.

The National Injury Committee for InjuryPrevention and Control states: “Trauma caresystems have been proven effective inreducing injury-related mortality andmorbidity. They are an essential

component of a systematic approach toinjury prevention from primary preventionthrough rehabilitation.” (Injury Prevention:Meeting the Challenge, 1989).

There is ample evidence in San Diego ofexcellent support from the trauma centers,government agencies, private foundationsand community organizations for injuryprevention efforts/programs. Numerousinjury prevention programs are directed bythe trauma centers. There is also clearevidence of collaboration between the EMSAgency and the many organizations withinthe community focusing on injury controlefforts.

San Diego EMS Agency &Prevention

The San Diego County EMS Agency hascreated an injury surveillance system. Thisdata system has been in existence for sevenyears and is fully integrated into many injuryprevention programs within San DiegoCounty. This system consists of collatingdata from the prehospital data set, traumacenter data set, the medical examiner’soffice, and law enforcement data. This injurysurveillance system is able to provide timelydata to organizations looking to identify theneed for specific injury prevention programsor to evaluate their existing programs. TheAgency also provides a stable source ofbaseline injury data to assist all injuryprevention programs in the community. Itis evident that the EMS Agency hasdeveloped strong collaborativerelationships with organizationssupporting and operating injury preventionprograms. The EMS Agency defines theirrole in these collaborative relationships asfollows:

34 R. M. Stewart, MD; J. G. Myers, MD; D. L. Dent, MD; P. Ermis, BA; G. A. Gray, MD; R. Villarreal, MD; O. Blow, MD, PhD; B. Woods, MD; M. McFarland, RN, MS;J.Garavaglia, MD; H.D. Root, MD; B. A. Pruitt Jr., MD. Seven Hundred Fifty-Three Consecutive Deaths in a Level I Trauma Center: The Argument for InjuryPrevention. J of Trauma, Jan 2003; 54(1):66-71.

35 F. Hulka, MD. Pediatric Trauma Systems: Critical Distinctions. J of Trauma, Sep 1999 47:S85-9.


§ provide data for evaluation and/orinjury prevention programimplementation

§ develop evaluation tools§ provide data for evaluation of program

effectiveness

The County of San Diego has developed anexceptional staff commitment to the studyof injury trends and injury prevention. TheEMS Agency has staff members dedicated toor supportive of their injury control andepidemiology programs. One component ofeach staff member’s scope of responsibilityis to provide data support to one subcom-mittee of Safe Kids, a local pediatric injuryprevention collaborative, operating as apart of a national injury preventioninitiative.

This injury surveillance system supportsmany injury prevention efforts within thecommunity. A few of these programs arelisted below:

§ CIREN§ Community Health Improvement

Partners, Violence Prevention WorkGroup

§ Motorcycle Safety Foundation and othercommunity based motorcycle groups

§ Numerous suicide prevention programs§ Pacific Safety Council§ Safe Communities§ Safe Kids§ Safe Routes to School§ San Diego State University: evaluation of

the data on adult and older adult injury

From 1997 to present, the EMS Agency hassubmitted an impressive 57 abstracts and/or poster presentations to the AmericanPublic Health Association, Association forHealth Services Research, CaliforniaCenter for Childhood Injury Prevention,Emergency Medical Services-Children, andthe Environmental Systems ResearchInstitute. All abstracts are injury control/epidemiological based.

One of the challenges at the EMS Agencylevel is meeting all of the demands of theircore function (e.g. prehospital and traumaregistry collection, assimilation andreporting) and responding to the variousspecial requests and special studies theAgency conducts. For example, theepidemiology staff has had a special interestin intentional injury and has reported andpublished a number of abstracts on thatsubject. However, much of the core workis strained as that special study work isaccomplished. The prehospital data set isroutinely behind by 18 months in terms ofscanning and the annual prehospital andtrauma registry report is not published anyearlier than 18 months from the close of theyear. While there are other factors thatimpinge on the Agency’s staff to producetheir reports in a more timely fashion, it isnot clear that, absent those limitations,the reports would be produced moreexpeditiously. It is also not clear who setsthe priorities of the EMS Agencyepidemiology staff and how well theirpriorities fit with the needs of the traumasystem.

Inventory of InjuryPrevention Programs

The inventory of injury preventionprograms within San Diego Countyrevealed a variety of programs offeredthrough various agencies both public andprivate. Some of these programs havetrauma center and or trauma systemrepresentation. Other programs representlocal efforts of state and/or nationalprograms. The San Diego County TraumaRegistry/Injury Surveillance data has beena data source for some of these programs.There is no central coordination center orclearinghouse for injury preventionprograms.

An inventory of trauma prevention programsby trauma center is as follows:

“One of the chal-

lenges at the EMS

Agency level is

meeting all of the

demands of their core

function (e.g.

prehospital and

trauma registry

collection, assimila-

tion and reporting)

and responding to the

various special

requests and special

studies the Agency

conducts.“


Children’s Hospital and HealthCenter

Children’s Hospital houses the Safe KidsCoalition. This is a 50-member collabora-tive of other injury prevention programsthroughout the county. The program ismanaged by a highly enthusiastic person.They received a grant from the Robert WoodJohnson Foundation in the amount of$265,928 for the period of 1-1-02 to 12-31-06.The grant title is Injury Free Coalition forKids: Dissemination of a Model InjuryPrevention Program for Children andAdolescents. Other prevention programsbased at Children’s Hospital include:

§ Bike Helmet Distribution Program§ Booster Seat Hotline§ Car seat Safety Checks§ CIREN§ Drowning Prevention program: “Water

Watcher” tags§ Multiple media events, and educational

printed material distribution§ “Safe Walk to School” Program

Palomar Medical Center

Palomar has a very active injury preventionprogram. All trauma patients are enteredinto their trauma registry for injury preven-tion and surveillance purposes. A few oftheir prevention programs are:

§ American Trauma Society’s “Trauma-Roo” Program

§ “Every 15 Minutes”§ CIREN§ Health Fairs

Scripps Memorial Hospital, La Jolla

Scripps La Jolla has a very active injuryprevention program.

§ Beach and Ocean Surf and Safety§ Blue Ribbon Campaign§ Child Passenger Safety§ CIREN

§ Corrective Behavioral Institute Pro-gram

§ “Every 15 Minutes”§ “La Pasada”§ “Red Light Running”§ San Diego Safe Communities 2000§ School Safety Program§ Various programs during Trauma

Awareness Month§ “Vial of Life”§ Yellow Ribbon Campaign

Scripps Mercy Hospital

Scripps Mercy has a full time nurse bud-geted for injury prevention and outreach.This staff person is very passionate aboutinjury prevention. The trauma center has apolicy to enter all patients into their traumaregistry specifically for injury preventionanalysis and surveillance.

Sample programs include:

§ AARP Senior Driver Safety Program§ Arrestee Drug Abuse Monitoring Pro-

gram (ADAM), Local Council§ California EMS Vision Implementation

Project: Prevention and Public EducationCommittee

§ Child Passenger Safety Educator Work-shops

§ CHIP: Violence & Injury Prevention WorkTeam

§ CIREN§ Community Health Improvement

Partners (CHIP): Suicide PreventionCommittee

§ “Every 15 Minutes”§ Methamphetamine Strike Force (MSF)§ Policy Panel on Youth Access to Alco-

hol§ Mid-City Safe Routes to School pro-

gram§ National Depression Screening Day§ Reflections of Hope Project§ Policy Panel on Youth Access to Alco-

hol§ Senior High School Trauma Internship

Program


§ Safe Communities 2000§ San Diego County Substance Abuse

Summit§ San Diego Safe Kids Coalition§ Screening and Brief Intervention Pro-

gram§ Teen Trauma Center Tour/Presentation§ “The Drug Store”§ “Truth & Consequences: Your Teen and

Drugs & Alcohol”§ Various public educational media events§ Yellow Ribbon Suicide Prevention

Program§ Youthful Drinking and Driving Program

Sharp Memorial Hospital

There is one full-time position, an InjuryPrevention Coordinator, under the auspicesof the Sharp HealthCare’s CommunityOutreach Division. This position is en-dowed and the staff person is very com-mitted to injury prevention. There isperipheral but indirect collaboration withthe Sharp Trauma Program. The scope ofresponsibility for the position is to coordi-nate injury prevention programs for theSharp Health System.

Specific programs under this positioninclude:

§ “Think First” program for elementary,middle and high school children, andcollege students.

§ Alternative School programs§ CIREN§ Injury and Violence prevention educa-

tion at health fairs§ “No More on 54”

An outcome evaluation of the “Think First”program was undertaken and the resultswere published in a peer-reviewed journal.Children in grades 1, 2, and 3 were includedin this study, and the results showed thatfollowing the implementation of this injuryprevention program, the control group hadincreased their knowledge regarding injuryprevention and high-risk behavior.

UCSD Medical Center

The injury prevention program at UCSDMedical Center is very extensive and there isfull time staff support for their programs.Samples of their programs are:

§ California Wellness Foundation (10-year grant)

§ Car Seat Safety program§ CBI (Correctional Behavioral Institute)§ CIREN§ “Cops and Docs”§ Crime Prevention Project for Youth§ “Prom Night”

Trauma Research & EducationFoundation (TREF)

Founded in 1983, TREF is a freestandingmember organization supported by thetrauma centers. TREF was originallycreated to provide a means for the traumacenters to work together for prevention,education and research. From the begin-ning, one focus/directive was injuryprevention. The affiliation between TREFand the trauma centers of San DiegoCounty is positive and supportive, and theyhave historically maintained an effectivepartnership. TREF’s executive director is adynamic and passionate advocate for theorganization.

One existing valued role of TREF is tosupport the trauma nurse education systemthroughout the county, thus allowing thetrauma centers to avoid duplicative costs.TREF also manages many projects onbehalf of the San Diego County EMSAgency and the trauma system.

Support and focus for TREF has varied inrecent years as the needed role of TREF,individual hospital commitment to theconcept, leadership and the needs of thetrauma centers have changed.


TREF, under new leadership, is undergoinga reinvigoration with targeted goals asfollows:

(1) Second Trauma - a curriculum develop-ment project with the American TraumaSociety that focuses on effective andcompassionate communication with thefamilies of the injured. The curriculumwill be trialed in San Diego County.

(2) Terrorist Bombing Readiness Project –TREF will trial a trauma center-basedreview of mass casualty plans in aneffort to teach the lessons learnedaround the world about casualty han-dling and the impact on healthcareservices.

(3) Binational Trauma Project – TREF willjoin with Baja California, Mexico traumacare professionals to create educationprojects for the nurses and paramedicsof their region. They will also explore apilot project to translate TRACS (ACSTrauma Registry) and TNCC intoSpanish and introduce the registry andthis curriculum to the Baja area.

(4) Lifesaving Device – TREF will partnerwith a company which makes a new andpromising life saving flotation devicewhich has proven effective in pool andlakeshore rescues.

(5) Prevention Programs – TREF will revisitold safety and prevention programs witha successful history. These includebicycle and pedestrian safety, beach andocean safety and other projects.

(6) Media Resource – TREF will become amore vocal and reliable media resourcefor injury and prevention activities.

(7) Governance Structure – TREF willenlarge its board to include morecommunity agency leaders - fire, police,schools, etc.

TREF’s current and recent past injuryprevention programs include:

§ Health and safety fairs§ Helmet and bicycle safety programs§ “Ocean Currents”§ “Red Light Running”

§ Seatbelt and restraint programs

Safe Kids Coalition, San DiegoChapter

The Safe Kids Coalition is a communitycollaborative program comprised of agencyrepresentatives and individuals united intheir efforts to make San Diego County asafer place for children. Coalition activitiesrange from conducting child safety seatcheck ups, to conducting drowning pre-vention campaigns and inspecting com-munity playgrounds for hazards. It ishoused at Children’s Hospital and targetschildren aged 0 to 14. All trauma centerswithin San Diego County are members ofthe Safe Kids Coalition. The Safe KidsCoalition produces a report every two yearscalled “Childhood Unintentional Injuries inSan Diego County: A Report to the Com-munity.” The Safe Kids Coalition is also amember of the local advisory committeefor the EMS for Children program.

Independent programs sponsored by theSafe Kids Coalition include:

§ Child passenger safety program§ Gun lock distribution program§ Helmet distribution program

Other injury prevention organizations/programs in San Diego include:

§ American Academy of Pediatrics, Califor-nia Chapter: Gun Safety Pilot Project

§ California Emergency Nurses Associa-tion

§ California Institute of TransportationSafety, San Diego

§ Child Care Services§ Children’s Safety Network (National

Injury Data Technical Assistance Center),San Diego

§ Community Health Education with Dr.Gerry Graf

§ Crash Injury Research and EngineeringNetwork (CIREN)

§ El Cajon Fire Department (SafetyEducation)


§ EPIC (Eliminate Preventable Injuries ofChildren)

§ First Monday: Unite to End Gun Vio-lence

§ Injury Free Coalition for Kids§ Navy Environmental & Preventative

Medicine Unit No. 5, San Diego§ Resources on Teen Violence, San Diego§ Safe Communities – a campaign to

create community coalitions to reducetraffic crash injuries and deaths. Theyhave pulled together existing pro-grams/groups and have received 2grants: one focused on the city, and thesecond focused on the county.

§ San Diego City Attorney’s DomesticViolence Unit

§ San Diego County Health & HumanServices Agency

§ State & Territorial Injury PreventionDirectors’ Association

§ The Center for Injury Prevention Policyand Practice (at San Diego State Univer-sity Graduate School of Public Health)

§ Think First§ UCSD School of Medicine Center for

Youth Violence Prevention§ YMCA: Child Care Health Consultant

Service

Target Populations

Through the use of the injury surveillancedata system at the San Diego County EMSAgency, epidemiological injury control/injuryprevention programs are matured and fullyintegrated into many collaborativecommunity injury prevention programs.Trauma Centers are all fully engaged ininjury prevention programs. Some of thetrauma centers are actively involved in injuryrelated research.

Data Sources

The data sources used by the traumacenters to tailor prevention programsinclude:

§ EMS Agency Injury Surveillance Data-base (which accesses multiple data-bases)

§ Hospital trauma registries§ Observed injury issues and/or identified

need§ Prehospital database (QANet)§ Other sources deemed appropriate for

injury control

Legislative Initiatives

SB69: a community partner’s bill requireshospitals to provide evidence of doingcommunity service to their area. The SanDiego County EMS Agency assists thetrauma centers with this process.

Observations

Direct funding and grant dollars for pre-vention activity between the traumacenters vary. For the most part, all sixtrauma centers have substantial commit-ments to trauma prevention as witnessedby their expenditures, number of programsand staff commitment. The San DiegoCounty EMS Agency is also substantiallyinvolved with injury prevention. TheCounty also relies heavily on grant moneyfor injury prevention efforts.

There is strong commitment and a cultureto support injury prevention from all traumacenters and the San Diego County EMSAgency. This commitment lends itself to anopportunity to collaborate in creative waysto meet the needs of the community and theorganizations leading the various programs.

There is significant variation among thetrauma centers regarding prevention targets.Most are matched to the mission of thehospital and to the hospital and traumaprogram needs and interests. The onecentral focus from all trauma centers isthrough TREF, but its prevention missionhas been scaled back in recent years. TheSafe Kids Coalition is the primary focus formost of the injury prevention programs. It


is not clear whether the Safe Kids Coali-tion, TREF or the individual trauma cen-ters’ initiatives are based on the epidemi-ology of cases in the trauma system.

Because of the high level of dedication andthe focus on specific sectors of injuryprevention, a central source or clearing-house for all injury prevention programswould greatly assist with coordination,reducing duplicative programs and optimiz-ing trauma center injury prevention re-sources.

One of the challenges of obtaining accu-rate and timely injury epidemiology data isthat the data set submitted by each traumacenter to the trauma registry varies accord-ing to the software. This may impact thequality of data available for true epidemio-logical based injury prevention efforts. Ifcompatibility of the prehospital databaseand the trauma registry were possible, theresulting data could be used to moreaccurately target and address specificprevention programs.

Once the databases are coordinated, thenopportunities for targeted trauma systemprevention programs could be identified.One method to identify areas of weakness inthe San Diego area is to use a matrixsimilar to what is used by the CDC toclassify the types of injuries reported (i.e.,rows represent mechanism (not blunt/penetrating), but motor vehicle, othertransport, firearm, fall, etc. The columnsrepresent the intent such as unintentional,intentionally inflicted by another, self-inflicted. Each project/program in theinventory could be entered in the appropri-ate cell. Apparently San Diego was one ofthe first EMS systems to adopt the meth-ods. Data has been collected and trendedsince 1998 in this fashion. This matrix withinjury rates should be published and usedby the trauma centers to identify “gaps.”

vehicle injuries in children, the rate may bevery low, but with multiple programs/projects, whereas falls in the elderly mightonly have one program. Not only couldthis identify gaps for the trauma centersand the system for future projects/pro-grams, it could also show where there is aconcentrated effort and where that injuryhas been reduced. Another considerationwould be to include only those “cells” thatare particularly applicable to trauma centerpatents as opposed to for injuries on thewhole.

Stable funding is a problem for almost allinjury prevention programs. When a facilityor system is having financial difficulties,prevention is typically one of the firstcategories to get cut, as has been wit-nessed in San Diego. Leveraging the workof other trauma centers and collaboratingon trauma system epidemiology wouldassist in providing more cost effectivetrauma patient prevention initiatives.

Trauma systems inherently need preven-tion programs as the work for the injureddoes not start with the care deliverysystem. As was stated by the NationalCommittee for Injury Prevention andControl:

“Support for the development ofcomprehensive trauma care sys-tems by all levels of governmentand by the health care and publichealth professions must be apriority. Trauma care systems havebeen proven effective in reducinginjury-related mortality and morbid-ity. They are an essential componentof a systematic approach to injuryprevention from primary preventionthrough rehabilitation.” 36

36 “Injury Prevention: Meeting the Challenge”. The National Committee for Injury Prevention and Control, 1989, Oxford Press, New York, NY.

“Leveraging the work

of other trauma

centers and collabo-

rating on trauma

system epidemiology

would assist in

providing more cost

effective trauma

patient prevention

initiatives.”

For example, in the cell labeled motor


Trauma System QualityImprovement

Overview

Trauma system and trauma center qualityimprovement are critical features for assur-ing optimal outcomes for trauma patients.The level and extent of a trauma system’squality improvement process is dependanton the expectations of the system, theindividual trauma centers and the publicthat they serve. It is clear that in SanDiego the expectations for quality andquality monitoring of trauma care are veryhigh.

In evaluating the trauma system’s qualityimprovement program in San Diego County,The Abaris Group believes it is importantto distinguish between quality care issuesand quality system issues. The formertends to orient to patient care events andthe latter to the performance and viabilityof the trauma system. Contemporarytrauma systems should include systemquality improvement initiatives thatevaluate system operations, changingtrauma epidemiology, market conditionsand trends.

To conduct the quality improvement (QI)review of the San Diego trauma system, TheAbaris Group conducted a meticulousexamination of the trauma center andsystem quality improvement processes,methods and outcomes. This included adetailed review of key documents, policiesand practices already in place for qualitytrauma review. Among items reviewedwere trauma center survey reports andaudits, MAC minutes for the past threeyears, quality assurance (QA) proceduresand policies, and resource tools provided bythe hospitals and the County. The AbarisGroup also conducted side-by-side audits of

the hospital quality improvement processat each trauma center.

In addition, The Abaris Group extensivelydiscussed the MAC process and its expecta-tions and outcomes in interviews with awide range of system stakeholders, reviewedall materials related to the process includingPre-MAC and MAC case binders, andobserved two MAC meetings. The AbarisGroup’s independent and objective expertteam conducted the review. This teamincluded a trauma neurosurgeon, an EMS/ED physician, a pediatric trauma surgeon,a trauma surgeon, and a trauma systemnurse manager.

San Diego Trauma QualityReview

In San Diego, quality review of the acutecare portion of trauma care is an extremelyhigh priority for the trauma centers and thesystem as a whole and is conducted bothinternally at each trauma center and system-wide. System-wide, quality review is con-ducted by the Medical Audit Committee(MAC). MAC is the countywide committeeused to review actual clinical cases todetermine potential for performance im-provement. Pre-MAC is a screening processconducted to determine which cases areforwarded to MAC for review.

MAC Process

At each trauma center, cases are regularlyreviewed at the trauma mortality and mor-bidity (M&M) committee. While eachtrauma center has a slightly different pro-cess for internal review, there is consistencyamong the trauma centers at determininghow cases enter the MAC process. Theyconduct their individual reviews, conductthe preparatory work for the Pre-MAC (keyrepresentatives conduct the Pre-MACreview) and then participate in the MAC

“It is clear that in

San Diego the

expectations for

quality and quality

monitoring of

trauma care

are very high.”


meeting. This entire process, known as the“MAC Process” uses rigidly defined pro-cesses such that the level of review isconsistent.37

A number of MAC’s trauma medicaldirectors and trauma program managershave participated on the committee sincethe programs early inception – providing ahigh level of institutional knowledge. MACand Pre-MAC membership are presented inthe tables below.

The MAC committee pro-cess underwent a scopechange slightly greater thana year and now only com-pletes patient quality reviewevery other month withsystem policies and admin-istrative matters dealt within the alternative month. TheCIREN crash reviews arealternated with the adminis-trative reviews every quarter.The Pre-MAC processremains unchanged, andMAC works to get twomonths worth of caseshandled at the bimonthlyclinical meeting.

In addition, audits of eachtrauma center are conductedannually by the San DiegoCounty EMS Agency andevery three years through theAmerican College of Sur-geons’ Trauma CenterVerification process.

When San Diego systemstakeholders were asked about thestrengths of the San Diego trauma system,the most frequent response was the MACprocess itself particularly in terms of itsintegrity, vigorousness and the credibility

and confidence that it lends to the entireEMS system.

Cases are initially reviewed at the traumacenter level (including review by eachcenter’s trauma medical director) and thenforwarded through a formal Pre-MACprocess for consideration for MAC review.Deaths are identified following review bythe Medical Examiner. The autopsies andother Medical Examiner reports of alltrauma-related deaths for all hospitals are

sent to MAC participants for review. Casesraising questions are then forwarded to theMAC through the Pre-MAC process.Additionally, the San Diego County EMSAgency QA Specialist for Trauma reviewsscene deaths and also forwards cases thatraise questions.

37 “Trauma Quality Assurance System”, County of San Diego, Health & Human Services Agency, Division of Emergency Medical Services, 2002.

Pre-MAC Review Team MembershipTwo Co-Chairpersons of MACOne Trauma Medical Director (rotating)One Trauma Medical Director assigned to review non-trauma center deathsThe Emergency/Base Hospital Medical Director (PAC Representative)An Emergency Non-Base Hospital/Non-Trauma Center RepresentativeThe EMS Trauma Quality Assurance SpecialistThe EMS Base Hospital Quality Assurance Specialist

Exhibit 15 - Pre-MAC Review Team Membership

MAC Committee MembershipTrauma Center Medical DirectorsTrauma Center Program ManagersCounty Medical ExaminerTrauma System Surgical ConsultantCounty Trauma System CoordinatorCounty Trauma Quality Assurance SpecialistBase Hospital Physician representing PACNeurosurgeonAnesthesiologistOrthopedic SurgeonEmergency Medicine Physician from non-Trauma Center

Exhibit 14 - MAC Committee Membership


The goal of MAC is to assure consistentquality of care at the trauma centers andknowledge sharing between the represen-tatives of each trauma center. FollowingMAC discussion, cases are brought backto quality review sessions at the individualtrauma centers.

Data Access/Use

Trauma registry data is forwarded to theCounty and the County screens the data forinclusion criteria meeting the NationalTrauma Data Bank (NTDB) criteria. Overtime there has been a rising concern overdata security and use of the data outsidevery standardized reporting formats. Forexample, today the County is not permittedto publish trauma center-specific data in anymanner, including raw volume. The com-plete data repository, part of the registry, isnot permitted to be used, and this limitsthe County from doing off-line qualitycontrol or conducting trend analysis. Thereare also concerns about data integrity andconfidence in the County’s use of the data.

There are variables outside the County’scontrol relative to the timely publication ofdata. These variables include the timing ofdata delivery, compliance with the comple-tion of key data fields, variation of hospitalinclusion criteria and the monitoringprocess of data publication that have beenimposed by the trauma centers on theCounty. These significant variables limitthe County relative to their practical andtimely publication of relevant data.

Prehospital System

There are some gaps in prehospital coordi-nation and an apparent disconnect betweenprehospital stakeholders and the traumacenters and MAC. As previously noted theMAC process does not have a significantrole for prehospital stakeholders and yetprehospital issues were prevalent duringThe Abaris Group’s observation sessions.

This gap varies by hospital and the issuesare sometimes conflicting at some hospi-tals. EMS outreach may be strong at onehospital, but the same hospital may havecommunications problems with theirprehospital caregivers. By being moreinclusive in considering issues ofprehospital care, the MAC process andMAC leadership could lessen this discon-nect which appears to be present.

Observations

The demonstrated focus and strength ofthe MAC process is its sophisticatedquality assurance model for clinical casemanagement. The Abaris Group has thefollowing additional observations regard-ing the quality review process:

§ The Pre-MAC process is consistentamong the hospitals. There is somevariation among the hospitals in termsof which patients are included but allsubmit the minimum data set requiredby the County of San Diego, leading tothe comparison of “apples with apples.”

§ All centers, trauma directors and traumaprogram managers participate at a veryhigh and credible level.

§ The Pre-MAC process as outlined in theCounty procedures and articulatedduring interviews with the County andtrauma center staff is complete andfactual.

§ Trauma surgeons, who are Pre-MACreviewers, do an excellent job of identify-ing cases that warrant group discussionas cases of interest or care concerns.Both trauma centers and case reviewerstake the process seriously.

§ The Pre-MAC process results in identify-ing individual cases needing furtherreview and there are above averagequality review protections at each of thetrauma centers.

§ The cases selected for review arerepresentative of the actual populationof cases and there does not appear tobe any bias or error in case selection.

“These significant

variables limit the

County relative to

their practical and

timely publication of

relevant data.”


§ The MAC meetings observed werepositive (non-confrontational buteducational).

§ Through review of the minutes andobservation at meetings, there wasstrong surgeon lead discussion at themeetings. The Level I trauma centerdoes not appear to dominate or overlyinfluence the meetings.

§ The cases are discussed in a mannerwhich is constructive and directed toidentification of correctable errors.

§ Through the discussions, efforts aremade to identify system errors, physi-cian-related errors, and institutionalerrors which can be avoided in thefuture.

§ Trauma surgeons from the traumacenters provide a frank and honestpresentation of their cases and identifyand disclose patient cases in whichoutcomes or elements of care wereeither unusual or problematic.

§ Deaths are categorized as non-pre-ventable, potentially preventable, orpreventable. Regardless of the desig-nation, a careful analysis is performedto permit improvements in patientcare and outcome. Similarly, compli-cations are carefully analyzed.

§ Difficult cases are presented that allowdiscussion of new treatment or diag-nostic modalities, and alternative butaccepted treatment strategies.

§ There is a flavor of “sport” involved inthe interaction among trauma surgeonsand in the presentation of hospitalcases to the group which adds to thepositive character of the review.

§ During our review of the MAC minutesand observation sessions, prehospitalissues were appropriately referred tothe Prehospital Audit Committee(PAC).

There are many strengths to the MACprocess, not the least of which are the in-depth case review and the educational andtrauma clinical practice-modifying nature ofthe process. However, the Pre-MACprocess is time consuming and excessive.

Almost all of the trauma program manag-ers stated that they spend a significantamount of time preparing the Pre-MACbinder. There were some differencesamong the trauma centers in terms of thenumber of support staff for this processand whether they were full time or parttime.

Despite a difference in perception amongthe trauma directors regarding the fre-quency of occurrence, the need to provideadditional dictation about non-outliercases occurs rarely. Based on The AbarisGroup’s review, the range is from once ortwice per year to once in ten years. Whenadditional dictation is requested, it isusually not a QA issue but, rather some-thing of educational merit, an interestingcase, or the like.

Consideration of prehospital trauma issuesis somewhat limited at MAC, based on areview of MAC minutes and some atten-dance issues. The participation of nonsurgeons is also minimal. The entire MACmeeting is structured to address QA issuesat the physician level. The non physicianparticipants supplement information in-cluded in reports and respond to specificquestions at the meeting. There is littleparticipation by the trauma program manag-ers except for a report on their monthlymeeting and an occasional comment.

San Diego County EMS Agency participa-tion is extensive in terms of preparationand meeting attendance, although perhapsexcessive in number of staff. This is appar-ently at the request of the trauma centersand the desire for this level of involvement isapparent at other meetings as well (e.g.Trauma Nurse Coordinators meeting).However, at the MAC meetings and duringinterviews, the EMS Agency staff demon-strated no significant role in the MACprocess in spite of MAC’s billing as thevehicle for system QA. There is no dataprovided on the “system” and no realtrauma system focus to the clinical MACmeetings or in any other forum that could


be determined.

While there has been some refinementover the years, the Pre-MAC and MACprocess is essentially unchanged since thetrauma system was initiated. The traumacenters strongly believe that the Pre-MACand MAC process in its present format isnecessary to maintain quality control andcontinue the educational benefits of theprocess.

The actual Pre-MAC process and how itleads to MAC is also very labor intensive.The process is also event- and audit-basedand as such does not address the trending,global care or process improvement needsthat characterize a mature trauma system ordeal with the multitude of strategic issuesthat the system will continue to face.

There are some shortcomings in traumasystem data collection and performancereview processes which are not adequatelyaddressed through a combination of theMAC and the trauma center review pro-cesses (annual and ACS). These are mostlytrending, strategic and financial. Virtuallyall trauma directors and trauma programmanagers would like additional trendeddata from the County. This includesregistry data reporting on the trends andoutcomes of different injuries (e.g. injurieson the rise or decline, etc.). There is realinterest among trauma directors andprogram managers to be able to comparetheir results with the other centers andwith the system as a whole. Lastly, there isvast data on systems operations at mul-tiple levels which lends itself to researchand reporting on process, outcomes andsystem design. The San Diego TraumaSystem is on the cusp of making addi-tional important contributions to traumasystems across the country through moretrended use of the robust data warehousethat it maintains.

“The San Diego

Trauma System is on

the cusp of making

additional important

contributions to

trauma systems across

the country through

more trended use of

the robust data

warehouse that it

maintains.”


IV. Data Analysis

Overview

Data for this study were drawn from bothpublic and proprietary sources. The Countyof San Diego defined data sets to be col-lected as part of the study that includedoverall hospital demand, cost and revenuedata, and trauma-specific data. The AbarisGroup added to the data collection processadditional data that would assist TheAbaris Group in completing its analysis ofthe trauma system.

During the trauma center site visits,clinical and financial data were collectedregarding hospital-wide, ED, andtrauma services.Supplemental datawere collected fromthe Office of State-wide Health Plan-ning and Develop-ment, Medicare CostReports, the SanDiego County EMSAgency’s TraumaRegistry and theQANet, and therecently-completedstudy by PhoenixHealthcare Consult-ing. The Abaris Group also collectedpopulation-based data from SANDAG.

Agreement was reached between theCounty of San Diego and the traumacenters that publicly available data couldbe disclosed in the report to the degreethat it was from public sources but propri-etary data would only be used in a summa-rized fashion. The Abaris Group alsoagreed to review a previously completedtrauma cost and revenue study (PhoenixHealthcare Consulting) and to the extentneeded, use portions of that study as thebasis for the cost and revenue portions ofthis study.

Trauma Patient Demo-graphic Profile

The Abaris Group conducted an overviewof trauma center patient demographicsusing the data from the San Diego CountyEMS Agency’s Trauma Registry for 2001and the Prehospital Database for FY 2000.

The data, as summarized on the followingexhibits, demonstrates that the mostfrequent age group for trauma was 25-35years of age. In 2001, the most commonrace/ethnicity was White (55 percent),followed by Hispanic (29 percent). Malesaccounted for 70 percent of the cases andfemales 30 percent.

Source: SDEMSA Trauma Registry, n = 5,123.

San Diego County Trauma by Age Cohort, 2001

0100200300400500600700800900

1000

0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75+

Exhibit 16 - San Diego County Trauma by

Source: SDEMSA Trauma Registry, n = 5,120.

San Diego County Trauma by Sex, 2001

30%

70%

MaleFemale

Exhibit 17 - San Diego Trauma by Sex


As part of the survey oftrauma center patients,The Abaris Group usedSan Diego’s TraumaRegistry CY 2001 to listthe frequency of diag-noses and surgicalprocedures (multiplediagnoses are reported forindividual patients). Themost frequent diagnoseswere open head woundsand concussions frac-tures. The most frequentsurgical procedures arealso listed in Exhibit 20(reporting hospitals only). Source: SDEMSA Trauma Registry, n = 5,120.

San Diego County Trauma by Race/Ethnicity, 2001

6.9%

29.4%

7.0%

54.8%

1.9%

WhiteBlackHispanicAsian/OtherUnknown

Exhibit 18 - San Diego Trauma byRace/Ethnicity

San Diego County Trauma SystemTop 20 Diagnoses, 2001

Description CasesPercent of

TotalOther Open Wound Of Head 1,449 7.5%Concussion 1,066 5.5%Fracture Of Face Bones 856 4.4%Fracture Of Rib(S), Sternum, Larynx, And Trachea 755 3.9%Fracture Of Vertebral Column Without Mention Of Spinal Cord Injury 720 3.7%Subarachnoid, Subdural, And Extradural Hemorrhage, Following Injury 717 3.7%Contusion Of Trunk 676 3.5%Sprains And Strains Of Other And Unspecified Parts Of Back 601 3.1%Superficial Injury Of Face, Neck, And Scalp Except Eye 558 2.9%Contusion Of Face, Scalp, And Neck Except Eye(S) 540 2.8%Intracranial Injury Of Other And Unspecified Nature 468 2.4%Fracture Of Tibia And Fibula 456 2.3%Cerebral Laceration And Contusion 455 2.3%Fracture Of Pelvis 437 2.2%Fracture Of Radius And Ulna 397 2.0%Superficial Injury Of Hip, Thigh, Leg, And Ankle 388 2.0%Traumatic Pneumothorax And Hemothorax 360 1.9%Contusion Of Lower Limb And Of Other And Unspecified Sites 330 1.7%Injury To Heart And Lung 324 1.7%Fracture Of Base Of Skull 305 1.6%Other 7,575 39.0%Total 19,433 100.0%Source: SDEMSA Trauma Registry

Exhibit 19 - Most Frequent Diagnoses of Trauma Patients


Exhibit 21 - Trauma Patients by ISS Distribution

The Abaris Group also reviewed the distribution of Injury Severity Scores (ISS). Thefollowing chart shows that about half of all trauma patients have an ISS score in thegroup 1 to 8, while 35 percent of trauma patients had an ISS of 9 to 15. Only 5 percent ofSan Diego County trauma patients had scores greater than 31.

The Abaris Group also used the San Diego County EMS Agency Prehospital Dataset forFY 2000. This data base has additional data points and there are geographic identifierswhich allows for mapping capability. These are EMS transports only and do not reflectthe total trauma volume. There were 6,445 trauma transports for FY00 of which 6,113records had identifiable subregional areas (SRAs) for mapping.

Exhibit 20 - Frequent. Trauma SurgicalProcedures

Procedure CasesPercent of Total

Exc Debrid Wound-Infec/Burn 490 6.1%Sut Skin & Subq Tiss-Oth Sites 364 4.5%Nonexcisional Debrid Wound-Infec/Burn 305 3.8%Op Reduc Fx W/Int Fix-Tibia & Fib 263 3.3%Explor Laparotomy 245 3.1%Op Reduc Fx W/Int Fix-Fem 219 2.7%Oth Wound Irrig 200 2.5%Op Reduc Fx W/Int Fix-Oth Bone 135 1.7%Applic Splint 123 1.5%Op Reduc Fx W/Int Fix-Radius & Ulna 116 1.4%Temp Tracheostomy 115 1.4%Debrid Op Fx-Tibia & Fib 112 1.4%Applic Oth Cast 111 1.4%Oth Repr & Recon Skin & Subq Tiss 93 1.2%Insrt Intercostal Drain Cath 87 1.1%Op Reduc Mandib Fx 80 1.0%Oth Skin Gft Oth Sites 74 0.9%Oth Craniotomy 73 0.9%Op Reduc Fx W/Int Fix-Humerus 69 0.9%Venous Cath-Nec 63 0.8%Other 4,670 58.3%Total 8,007 100.0%Source: SDEMSA Trauma Registry

San Diego County Trauma SystemTop 20 Trauma Surgical Procedures, 2001

Source: SDEMSA Trauma Registry, n = 4,566

San Diego County Trauma Patients by ISS Range, 2001

0%

10%

20%

30%

40%

50%

60%

1-8 9-15 21-30 31-40 41-50 51-60 61-70 71-75


This following map illustrates the volume of trauma cases by sub regional area (SRA).The SRAs with the highest volume of trauma cases are those around the cluster of fourtrauma centers (Sharp, Children’s, UCSD and Scripps Mercy), except for one SRA alongthe western portion of the Mexican border.

Catchment Boundary

Palomar Catchment

Sharp Catchment

Mercy Catchment

Scripps Catchment

UCSD Catchment

Palomar MC

Scripps La Jolla

Children'sSharp Mem.

UCSD Scripps Mercy

Trauma Case Volumeby SRA

500 to 611 cases400 to 499 cases250 to 399 cases100 to 249 cases40 to 99 cases11 to 39 cases

Exhibit 22 - Trauma Volume by SRA

Source: SDEMSA Prehospital Dataset FY2000, n = 6,113


Catchment Boundary

UCSD Catchment AreaMercy Catchment Area

Sharp Catchment Area

Scripps Catchment Area

Palomar Catchment Area

Scripps MercyUCSD


Scripps La Jolla

Palomar MC

Trauma Case Rate by SRACases per 1000 People

10.1 to 10.83.5 to 10.02.75 to 3.41.5 to 2.740.5 to 1.4

Exhibit 23 - Trauma Utilization Rate per 1,000 People by SRA

This map depicts the trauma case rate per 1,000 population. The case rate is high forthe two SRAs in the east because they have very little population and any increase intrauma injuries will result in dramatically higher case rate38. There are five SRAs withrates between 3.5 to 10 traumas per 1,000 people.

38 They have major roadways (Interstate 8, etc.) which bisect their entire east – west width, undoubtedly adding to their overall trauma numbers. In other words,they have a very low resident population but probably a relatively high transient population. Thus, their trauma rate is more reflective of the transient population(motor vehicle crashes and related) than the trauma from the resident population. Any increase in trauma numbers will reflect dramatically in their rate, due totheir low resident population denominator, as opposed to the SRAs with high population numbers, which will require a major shift in their trauma number tohave a substantial impact on their rate.



Motor vehicle crashes (MVCs) are a major source of traumatic injury – they accounted foralmost 53 percent of all trauma cases. The second most frequent injury is falls(15.8 percent).

The following map illustrates the MVCs by SRA. The SRAs with the greatest number ofmotor vehicle crashes are in the Scripps La Jolla, Sharp, UCSD and Scripps Mercycatchment areas.

Exhibit 25 – Motor Vehicle Crashes by SRA

Exhibit 24 – Causes of Traumatic Injury

CauseTotal

CasesPercent of

TotalMotor Vehicle Related 3,386 52.5%Falls 1,020 15.8%Blunt Trauma 326 5.1%Cut-Pierce 321 5.0%Firearms 165 2.6%Pedalcycles 152 2.4%Other 1,075 16.7%Total 6,445 100.0%Source: SDEMSA Prehospital Dataset, FY 2000, n = 6,445

San Diego County Trauma SystemCause of Injury, FY 2000


Catchment Boundary





Scripps MercyUCSD


Scripps La Jolla

Palomar MC

Motor Vehicle Crash Volumeby SRA

150 to 22780 to 14950 to 7920 to 496 to 19


Source: SDEMSA Prehospital Dataset, n = 4,621

San Diego County Intent of Injury, FY 2000

75.0%

2.3%

1.4%

0.4%0.8%14.2%

6.0%Assault

Domestic Assault

Legal Intervention

Not Known

Other

Self Inflicted

Unintentional

Exhibit 26 - Trauma by Intent of Injury


San Diego County All Trauma by Day of Week, FY 2000

-

200

400

600

800

1,000

1,200

1,400

Sun Mon Tue Wed Thu Fri Sat

Exhibit 27 - Trauma by Day of the Week


The SDEMSA Prehospital Dataset for FY 2000 also provided response times to the traumascene in San Diego County. For 14.4 percent of the patients the response time was lessthan 5 minutes to respond, while 50 percent of the time the response time was 5 to 9minutes to respond. 22.6 percent of trauma patients were responded to within 10 to 15minutes. Only 13 percent of trauma patients in San Diego County experienced a re-sponse time greater than 16 minutes.

Source: SDEMSA Prehospital Dataset, n=6,388

San Diego County Causes of Injury by Hour of Day, FY 2000

050

100150

200250300350

400450

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23Hour of Day

Exhibit 28 - Trauma by Hour of the Day


San Diego County Response Times for Trauma, FY 2000

0%

10%

20%

30%

40%

50%

60%

< 5 5 - 9 10 - 15 16 - 20 21 - 30 > 30 Minutes

Exhibit 29 - Response Time to Trauma Scene


This following map illustrates the average ground ambulance response time by SRA. Theresponse time is the difference between the time an ambulance receives a call and the timeit arrives on the scene. Some of the SRAs with longer response times (core San Diego area)are most likely experiencing delays due to traffic conditions. Other areas with higher re-sponse times are impacted by longer distances to the scene.

Exhibit 30 - Average Ground Ambulance Response Time by SRA

Source: SDEMSA Prehospital Dataset FY2000

Catchment Boundary





Scripps MercyUCSD


Scripps La Jolla

Palomar MC

Average Ground AmbulanceResponse Time by SRA (in minutes)

6.8 to 8.58.6 to 9.79.8 to 10.8

10.9 to 15.815.9 to 25


The Abaris Group completed a similar analysis of prehospital data for scene times.Scene time is defined as the the differnce between the time the ambulance arrives at thescene to the time it is enroute to the hospital. One quarter of trauma patients weretransported in less than 10 minutes, while the greatest percentage of transports (or 35.7percent) occurred within 10 to 15 minutes. 18.1 percent all patients were transported in21 minutes or more.


San Diego CountyTrauma Patients by Scene Time, FY 2000

0%

5%

10%

15%

20%

25%

30%

35%

40%

< 10 10 - 15 16 - 20 21 - 30 31 - 40 > 40Minutes

Exhibit 31 - Scene Time for Trauma Patients


This map depicts the average ground transport time by SRA. Transport time is definedas the difference between the time an ambulance departs a scene and the time it arrivesat a trauma center. All SRAs surrounding the trauma centers have an 8.8 to 13.7 minutetransport time, reflective of their short transport distance (with the exception of one SRAin the Sharp catchment area).

Exhibit 32 - Average Ground Ambulance Transport Time by SRA

Source: SDEMSA Prehospital Dataset FY2000

Catchment Boundary





Scripps MercyUCSD


Scripps La Jolla

Palomar MC

Average Ground AmbulanceTransport Time by SRA

8.8 to 13.713.8 to 15.916 to 18.418.5 to 21.521.6 to 33.3


SR 94

I - 805

Inte

rsta

te 1

5

Interstate 8

Highway 67

Highway 94

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

"Hot Spots"

UCSD

Sharp Mem. Children's

Scripps La Jolla

Scripps Mercy

Palomar MC

As part of the transport and response review, The Abaris Group accessed traffic flow datafrom SANDAG for highways in the County. Highway areas identified as “hotspots” bySANDAG (defined as average weekday speed less than 35 MPH for greater than 4 hours perday) are illustrated on this map with a thick blue line. There are several “hot spots” on theSan Diego highways. These areas may contribute to longer response and transport times ofground ambulance providers.

Exhibit 33 - Traffic "Hot Spots" in San Diego

Source: SANDAG, 2030 Draft Regional Transportation Plan,Technical Appendix 10


The following graph from the San Diego Trauma Registry shows the average length of stayfor trauma patients in San Diego County. According to the SDEMSA, the average length ofstay for trauma patients is approximately 5.5 days.

Nationwide Trauma PatientCharacteristics

To provide an overview of patient charac-teristics nationwide, The Abaris Groupreferred to The National Trauma Data Bank(NTDB) Report 2002, which describesnationwide trauma patient characteristicsfor the period 1994 to 2001.39 This databank is the largest aggregate of traumaregistry data ever assembled. The NTDBcontains 430,557 records from 130 traumacenters across the United States.

According to NTDB, nationwide traumapatient profiles share similarcharacteristics with those of San DiegoCounty. NTDB reported 64.2 percent of alltrauma cases were men, while San DiegoCounty reported 69.9 percent. NTDBreported that males outnumbered femalesby 3 to 1 in the 20- to 24 year-old agegroup.

When reported by age, NTDB data showthat the number of trauma cases peaked atages 17 to 24, declined and flattened outuntil the age of 40, then declined further

until a smaller second peak between ages72 to 85. NTDB reported 10.1 percent oftrauma patients were age 15 and under and24.9 percent were age 55 and over. The SanDiego County Trauma Registry reportedslightly different percentages, which were12.9 percent and 20.6 percent, respectively.NTDB showed a peak at ages 25 to 34,which is also what San Diego Countyreported. NTDB reported 17.3 percent oftrauma patients were 25 to 34, while SanDiego County reported 17.1 percent.

Like San Diego County, NTDB reported themost common mechanism of injury wasmotor vehicle related crashes, whichaccounts for 42.9 percent of all traumacases. However, this is about 10 percentless than what San Diego reported (53.1percent). The NTDB also reported falls asthe second most common mechanism ofinjury, at 30.4 percent, which is double SanDiego County’s at 15.8 percent. At thenational level, the third most commonmechanism of injury was gunshot woundsand for San Diego County, gunshotwounds were the fifth most commonmechanism.

39 American College of Surgeons on Trauma: National Trauma Data Bank Report. Chicago IL, 200240 The Abaris Group combined all motor vehicle related cases in one category, accounting for the slightly higher motor vehicle case rate.

San Diego CountyTrauma Patient Length of Stay, 2001

TotalAverage 5.5 N 5,108 Std. Deviation 8.9 Sum 28,044 Minimum - Maximum 120.8 Median 2.9 Average per day 76.8 Source: SDEMSA Trauma Registry

Exhibit 34 - Average Length of Stay


Trauma Center Descriptive& Financial Data

The following data provides an overalldescription of capabilities, defines overallhospital and trauma center demand, andsummarizes utilization statistics for thetrauma centers.

Hospital-Wide Data

The trauma center hospitals range in sizefrom 215 to 377 beds. There are a total of226 ICU beds, 1,064 medical/surgical bedsand 81 operating suites at these hospitals.In 2001, hospital admissions ranged from12,400 to 20,900 with an average of 16,800.The average daily census for total patientsranged from 201 to 365 patients with anaverage of 288. The number of admissionsfor the EDs at trauma centers ranged from5,044 to 10,758 with an average of 7,241. In2001, the percentage of overall admittedpatients admitted from the ED ranged from24 to 61 percent with the average of 44percent. In 2002, the average number ofadmissions from the ED was projected tofall to 6,860, with an average of 42 percentof admissions coming from the ED.

ED Data

There was a wide range of ED visits at thehospitals in 2001 from 26,500 to 63,400and a standard deviation of 11,300. Thepercentage of patients admitted to thehospital from the ED varied considerablyfrom 9 to 26 percent. This factor is anindication of the overall acuity of thearriving ED patient. Another factor is thenumber of ED patients defined as “critical”using the OSHPD definition41. The range atthe trauma centers was 2 percent to 44percent.

A cost to charge ratio for each traumacenter ED can be calculated from MedicareCost Report data by comparing the re-ported costs to reported charges. The ratiovaried considerably from 20 to 114 percentwith an average of 52 percent and a stan-dard deviation of 33 percent.

Trauma Department Data

In studying trauma systems, it is impor-tant to understand the different labels usedfor trauma patient categories. Exhibit 35summarizes the definitions used in SanDiego and provides summary data for eachdefinition.

41 OSHPD Definition of Critical EMS Visit: “a patient presents an acute injury or illness that could result in permanent damage, injury or death (head injury, vehicular accident, a shooting).”

Exhibit 35 - Trauma Patient Definitions

Term Definition Value9,351 (FY01);9,285 (CY01)

Trauma Transports Patients transported to a trauma center by EMS that meet trauma triage criteria 6,445 (FY99/00)Trauma Activations Full and modified trauma team activations 8,856 (CY01)Trauma Consults Patients not a “trauma activation” but receiving an evaluation by one or more

trauma team members for potentially traumatic injury.708 (CY01)

5,169 (FY01);5,123 (CY01)

7,224(FY01)includes 5,169 trauma registry patients above

Source: San Diego FY99/00 – Prehospital Database, FY01–Trauma Center Monthly Reports orTrauma Registry, CY01–individual trauma centers

Abbreviated Registry Patients

Patients meeting any of the following criteria: admission to the hospital (including LOS<24 hours); admission to an intensive or intermediate care unit; inter-facility transfer to or from an acute care hospital; or death from traumatic injuries

San Diego County Trauma Definitions

Trauma Arrivals Patients receiving care at a designated trauma center; includes patients transported to the trauma department from the scene by EMS (“Trauma Transports”), patients

Trauma Registry Patients Patients meeting any of the following modified MTOS criteria: admission to the hospital for at least 24 hours; admission to an intensive or intermediate care unit; inter-facility transfer to or from an acute care hospital; or death from traumatic injuries


Among the hospitals, trauma arrivals for CY2001 ranged from 1,200 patients to 1,900patients. Trauma triages and trauma activa-tions ranged from 1,200 to 1,800. Traumaconsults ranged from 67 to 146. Traumacase discharges from the ED ranged from 0to 596 for CY 2001 and 0 to 636 for 2002(projected based on data through Septem-ber 2002). Transfers in for 2001 ranged from24 to 288 and 31 to 344 for 2002 (projected).Transfers out ranged from 8 to 313 for 2001and 12 to 316 for 2002 (projected).

The percentage of trauma cases dischargedfrom the ED ranged from approximately 0percent to 47 percent for CY 2001 and 0percent to 48 percent for CY 2002 (pro-jected). This is likely due to practice varia-tions or variations in the use of the triagecriteria or both.

Trauma Center Costs

The cost for trauma care at the six traumacenters in FY 2002 ranged from $14.3million to $23.6 million, with the averagebeing $19.3 million. Using trauma cases,the resulting average cost of trauma careper patient ranged from $9,800 to$14,800, with the average being $12,000.This variation may be due to variations incosts, practice variations or cost allocationmethods.

Trauma centers provided their annual costof specialty physician call coverage fortrauma. Responses ranged from $940,000to $3.0 million, with the average being $1.7million.

Trauma program office costs includetrauma program manager, trauma medicaldirector and registry and other supportstaff. The range in costs were $175,960 to$1.318,000. With the exception of onehospital, these costs also reflect traumacase managers if they exist at the hospital.The hospital case manager costs at theone hospital are in a separate cost centerand could not be separately identified.

Even so the hospital's trauma programcosts were not the lowest. As such, varia-tion in trauma program office costs areconsiderably different. Differences in scopeof the trauma program office, level ofcontribution by other departments totraditional trauma program office func-tions or institutional priorities could allaffect these cost figures.

Trauma Center Revenue

Data from the Trauma Registry shows themedian charge at the trauma centers in CY2001 ranging from $11,800 to $37,000,with a median across all trauma centers of$27,000. Net revenue in FY 2002 fromhospital data ranged from $10.7 million to$31.8 million with an average of $22.1million and a standard deviation of $6.8million.

The trauma cost to revenue ratio rangedfrom 70 percent to 135 percent with anaverage of 93 percent and a standarddeviation of 22 percent. The followingcharts provide individual data requested bythe County of San Diego or The AbarisGroup to complete this study. Each tablesummarizes the data and describes thedata sources.

Table A: Hospital Data

Data ItemReporting

Period Children's PalomarScrippsLa Jolla Scripps Mercy Sharp UCSD Co

unt

Min Max Avg St DevHospitalTotal Hospital Beds (Available) As of 10/02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 215 377 307 50 ICU Beds As of 10/02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 24 66 38 14 Med/Surg Beds As of 10/02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 101 364 177 91 Surgical Suites As of 10/02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 10 17 14 3 Hospital Admissions CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 12,401 20,890 16,842 3,375 Hospital Admissions Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 10,449 23,948 16,931 4,632 Hospital Discharges FY01 OSHPD OSHPD OSHPD OSHPD OSHPD OSHPD 6 12,379 22,786 19,101 3,591

Number of Admissions from ED to Hospital CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 5,044 10,758 7,241 2,217

Number of Admissions from ED to Hospital Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 4,328 8,807 6,860 1,634 Percentage of Total Admissions Coming from ED CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 24% 61% 44% 13%Percentage of Total Admissions Coming from ED Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 24% 59% 42% 11%Average Daily Census FY01 OSHPD OSHPD OSHPD OSHPD OSHPD OSHPD 6 201 365 288 56 ALOS for all patients (excluding long-term care) FY01 OSHPD OSHPD OSHPD OSHPD OSHPD OSHPD 6 4.0 5.8 5.0 0.8

Source

Table B: Emergency Dept. Data

Data ItemReporting


unt

Min Max Avg St DevEmergency DepartmentED Visits (Hosp. data) CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 26,503 63,422 42,899 11,268 ED Visits (Hosp. data) Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 28,103 52,100 40,855 7,517 ED Visits (OSHPD data) CY01 OSHPD OSHPD OSHPD OSHPD N/R OSHPD 5 26,574 67,701 43,235 13,591

ED Visits Admitted to Hospital (Hosp. data) CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 5,044 10,758 7,241 2,217

ED Visits Admitted to Hospital (Hosp. data) Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 4,328 8,807 6,860 1,634 ED Visits Admitted to the Hospital (OSHPD data) CY01 OSHPD OSHPD OSHPD OSHPD N/R OSHPD 5 4,959 10,467 6,932 2,174 "Critical" ED Patients (OSHPD data) CY01 OSHPD OSHPD OSHPD OSHPD N/R OSHPD 5 1,048 16,625 6,288 5,564

ED Diversion Hours CY01 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 59 3,416 2,347 1,152

ED Diversion Hours CY02 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 22 2,718 1,818 928

ED Total Costs (000's) FY01 MediCal

Cost Report MCR MCR MCR MCR MCR 6 $ 4,794 $ 12,040 $ 9,267 $ 2,540

ED Total Charges (000's) FY01 MediCal

Cost Report MCR MCR MCR MCR MCR 6 $ 10,528 $ 32,711 $ 21,784 $ 7,175 Percentage of ED Visits Admitted to Hospital (Hosp. data) CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 9% 26% 18% 6%Percentage of ED Visits Admitted to Hospital (Hosp. data) Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 8% 25% 18% 5%Percentage of ED Visits Admitted to Hospital (OSHPD data) CY01 OSHPD OSHPD OSHPD OSHPD N/R OSHPD 5 8% 28% 17% 6%Percentage of ED Patients Designated "Critical" (OSHPD data) CY01 OSHPD OSHPD OSHPD OSHPD N/R OSHPD 5 2% 44% 17% 15%

ED Cost to Charge Ratio CY01 MediCal

Cost Report MCR MCR MCR MCR MCR 6 20% 114% 52% 33%

Source

Note: MCR stands for Medicare Cost Report, FY2001

Table C: Trauma Data

Data ItemReporting


unt

Min Max Avg St DevTraumaTrauma Arrivals CY01 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 1,223 1,927 1,548 255 Trauma Arrivals FY02 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 1,285 1,974 1,591 250 Trauma Triages CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 1,221 1,782 1,504 210 Trauma Triages Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 1,097 1,936 1,579 296 Trauma Activations CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 1,221 1,774 1,476 214 Trauma Activations Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 1,095 1,936 1,532 283 Trauma Consults CY01 Not Tracked Not Tracked Hosp. Hosp. Hosp. Hosp. 4 67 146 118 30 Trauma Activations Proj. CY02 Not Tracked Not Tracked Hosp. Hosp. Hosp. Hosp. 4 79 153 127 29 Trauma Registry Patients CY01 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 644 1,082 854 158 Trauma Admissions to Hospital CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 679 1,723 1,179 377 Trauma Admissions to Hospital Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 569 1,936 1,217 472 Trauma Discharges from ED* CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 0 596 324 192 Trauma Discharges from ED* Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 0 636 362 223 Trauma ALOS (MMTOS) CY01 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 4.3 6.6 5.5 0.8 Trauma Transfers In CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 24 288 158 96 Trauma Transfers In Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 31 344 176 98 Trauma Transfers Out CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 8 313 85 105 Trauma Transfers Out Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 12 316 90 106 Trauma Bypass Hours CY01 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 32 513 148 165 Trauma Bypass Hours CY02 SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA SDC EMSA 6 9 175 102 54 Median Trauma Charge (MMTOS pts.) CY01 SDC EMSA N/R SDC EMSA SDC EMSA SDC EMSA SDC EMSA 5 $ 11,769 $ 37,045 $ 27,022 $ 8,819 Specialty Physician Costs for Trauma (000's) As of 10/02 Hosp. Hosp. Hosp. Hosp. Hosp. N/R 5 $ 940 $ 2,992 $ 1,717 $ 696 Trauma Program Office Cost FY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 $ 175,958 $ 1,318,222 $ 629,259 $ 360,961 Trauma Costs (000's) FY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 $ 14,342 $ 23,562 $ 19,274 $ 3,773 Trauma Net Revenue (000's) FY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 $ 10,667 $ 31,842 $ 22,096 $ 6,792 Avg. Cost of Trauma Care per Pt. FY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 $ 9,837 $ 14,810 $ 12,126 $ 1,633 Percentage of Trauma Triages Admitted to Hospital CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 53% 100% 77% 15%Percentage of Trauma Triages Admitted to Hospital Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 52% 100% 74% 18%Percentage of Triages Discharged From ED* CY01 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 0% 47% 23% 16%Percentage of Triages Discharged From ED* Proj. CY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 0% 48% 26% 18%Trauma Cost to Revenue Ratio FY02 Hosp. Hosp. Hosp. Hosp. Hosp. Hosp. 6 70% 135% 93% 22%* Trauma discharges from the ED are estimated by the difference between Trauma Triages and Trauma Admissions to Hospital, not taking into account transfers or deaths.

Source


San Diego County TraumaVolume Projections

Purpose

Trauma patient volumes are an importantindicator of resource needs and capacitydemands for hospitals. They also assistwith predicting overall system resources.Future demand is also an importantelement of calculating future financialneeds of the system.

San Diego trauma center volume hasfluctuated by year with an average of 7.0percent over the 18 years of the program.During the past four years the growth hasaveraged 4.2 percent.

Methodology

Population changes have historically beenan important predictor of trauma volume. Inorder to confirm the predictive value for SanDiego, The Abaris Group ran a simple linearregression (using a time series of traumavolume as the dependent variable andpopulation as the independent variable).The findings demonstrated that there is areasonable linear relationship between thetwo42. Thus, The Abaris Group’s initialefforts focused on using population as thedriver for the volume projections.

The Abaris Group used four different meth-ods for predicting future trauma volumes:

(1) Projected based on population growthper zip code and compared to EMStransports by zip code

(2) Using historical utilization rates bytrauma center catchment area withtrauma center catchment projectionsprovided by the San Diego County EMSAgency

(3) Same as number two but adjusted forthe pediatric population

(4) Historical trauma volume change foreach trauma center using a weightedgrowth rate

While all four methods showed growth, thefirst three tended to understate growth(under two percent per year) which isinconsistent with historical growth eventhough the population growths weresimilar. Therefore, The Abaris Group chosethe fourth methodology as the principalsource for projections.

For this method, The Abaris Group reviewedthe historical change in trauma volume foreach trauma center. The historical data weresubmitted by each trauma center to the SanDiego County EMS Agency via the monthlyhospital trauma data reports. The percentchange was calculated for each year and aweighted average growth rate was developed(to smooth out the fluctuations experiencedby each trauma center). Using a weightedaverage is common in forecasting because,in general, it is believed that the recent pastis a better predictor of the future and shouldbe given more weight than the previousyears. The Abaris Group assigned thepercent change for FY02 the largest weight(50 percent) and the percent change forFY00 and FY01 were assigned a weight of 25percent each.

Using this projection method, traumavolume for the county is expected to risefrom FY2002 9,545 to 13,223 in FY 2010. Theannual growth rate is expected to be 4.2percent. These projections assume nochanges in the catchment area boundaries.

The following exhibit presents The AbarisGroup projections.

42 The Coefficient of Determination (R2) was .683 (a value of .70 and greater is considered good) and the Coefficient of Multiple Correlation (Multiple R) was .826(a value close to 1 indicates a strong relationship).

San Diego County Trauma Volume ProjectionsProjected Arrivals (or Admissions)Trauma Center Growth

FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY03 to FY10Children's 1,341 1,486 1,338 1,333 1,333 1,334 1,334 1,334 1,335 1,335 1,335 1,336 0.02%Palomar 1,163 1,143 1,160 1,285 1,353 1,426 1,502 1,582 1,666 1,755 1,848 1,947 5.48%Scripps La Jolla 1,109 1,284 1,469 1,458 1,563 1,675 1,795 1,924 2,061 2,209 2,368 2,538 7.80%Scripps Mercy 1,622 1,797 1,889 1,974 2,097 2,227 2,366 2,514 2,670 2,836 3,013 3,201 6.58%Sharp 1,571 1,646 1,818 1,771 1,816 1,861 1,908 1,956 2,005 2,055 2,107 2,160 2.37%UCSD 1,629 1,628 1,677 1,724 1,761 1,799 1,837 1,876 1,916 1,957 1,999 2,042 2.00%

Total 8,435 8,984 9,351 9,545 9,923 10,321 10,742 11,185 11,654 12,148 12,671 13,223 4.16%Percent Change - 6.51% 4.09% 2.07% 3.96% 4.02% 4.07% 4.13% 4.19% 4.24% 4.30% 4.36% -Annual Average Change - - - 4.21%Percent Change

FY99 FY00 FY01 FY02

3 Year Weighted

AverageChildren's - 10.8% -10.0% -0.4% 0.0%Palomar - -1.7% 1.5% 10.8% 5.3%Scripps La Jolla - 15.8% 14.4% -0.7% 7.2%Scripps Mercy - 10.8% 5.1% 4.5% 6.2%Sharp - 4.8% 10.4% -2.6% 2.5%UCSD - -0.1% 3.0% 2.8% 2.1%Source: SDEMSA Monthly Trauma Reports, The Abaris Group.

Actuals Projections


The following exhibits illustrate the current and expected trauma volume for the entirecounty and for each trauma center.

Exhibit 40 - San Diego County Actual &

Projected Trauma Volume

Exhibit 41 - San Diego County Actual & ProjectedTrauma Volume by Trauma Center

Source: SDEMSA Monthly Trauma Center Reports, The Abaris Group.

San Diego County Total Trauma VolumeActuals for FY99 - FY02 & Projected for FY03 - FY10

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10

Source: SDEMSA Monthly Trauma Center Reports, The Abaris Group.

Trauma Volume by Trauma CenterActuals for FY99 - FY02 & Projected for FY03 - FY10

-

500

1,000

1,500

2,000

2,500

3,000

3,500

FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10

Scripps MercyScripps La JollaSharpUCSDPalomarChildren's


Discussion

There are a variety of factors that affecttrauma volume. Clearly age distribution andepidemiology are critical factors. Accordingto SANDAG, the overall population growthrate is expected to be 1.4 percent per year,but the pediatric population (0 – 14) isexpected to be only .o4 percent per year.The projected population for San Diego isexpected to increasingly age. The olderpopulation (60 years plus) is expected togrow 3.4 percent (faster than the overallgrowth rate). Currently the population aged60 and older make up 14.4 percent, whilein 2010, that same segment will comprisealmost 17 percent of the total population.Older populations tend to have more co-morbid risk factors and their increasecould cause a rise in trauma cases. TheAbaris Group’s predictions show conserva-tive trauma center growth for pediatriccases and more substantial growth foradults.

An increase in prevention efforts couldalso decrease trauma cases, but historicaltrauma incidence rates in San DiegoCounty have remained high in spite ofrobust community prevention efforts.Increased daytime populations to highbusiness density areas could have athreefold affect by 1) increasing the dailypopulation to a trauma catchment area, 2)decreasing the population from the bed-room community it comes from, and 3)increasing risk along traffic corridorsduring commute times. Other factorsmight include the social and environmen-tal changes that affect a portion of motorvehicle crashes (improved roadways),assaults (increase in gang activity) or evenspecial events resulting in a populationspike (Super Bowl).

There are at least two other populationsthat impact the San Diego region – tour-ists and undocumented immigrants. Whilethe overall population growth in San DiegoCounty is projected to be modest, thereare a significant number of tourists whovisit the region annually. The San DiegoConvention & Visitors Bureau estimatedthe number of overnight visitors to SanDiego at 14.8 million in 2001 – almost fivetimes the region’s resident population.Also, not included in the populationprojections is the transient immigrantswho cross the Mexico/US border into SanDiego. The San Diego County TraumaSystem Plan 2002 cites the number oftransient immigrants at 2.9 million39.Baseline trauma volumes for FY02 alreadyinclude the volume generated from thesetwo unique populations. However, adramatic shift in these populations wouldaffect the trauma volume projections.

39 County of San Diego, Health and Human Services Agency, Division of Emergency Medical Services:County of San Diego Trauma System Plan 2002, p. 1-2.


Trauma Center FinancialProjections

Purpose

The Abaris Group compiled financial datafrom the trauma centers in San DiegoCounty to understand their current financialsituations and project changes over the nextseveral years. Some trauma center data usedin the calculations were also from thePhoenix Healthcare Consulting report.

Methodology

The Abaris Group met with each traumacenter and discussed their costs and rev-enue calculation tools. The method ofproducing revenue was consistent amongstall six hospitals. There were some variationin costing methods between the hospitalsbut all were able to use a method thatspecifically calculated trauma patient andservices costs to a level of detail andconfidence satisfactory to The Abaris Group.

Each hospital supplied data for fiscal year2002. San Diego County’s trauma volumedata for fiscal year 2002 (July – June) wereused for the base 2002 year. Minor differ-ences between the trauma center fiscalpatient volume and the County’s werethought to be due to timing as well asdifferent methods for hospital fiscalreporting compared to methods used atthe trauma registry level. Each hospital’srevenue and cost data were adjusted toreflect the appropriate volume of casesused.

The fiscal year data source was chosen asit more closely represented actual revenueand costs. However, there are slightvariations with the fiscal years. Threehospitals use July to June fiscal years and

tency of the annual trauma patient profilesfor each hospital.

Using the hospital data reported for fiscalyear 2002 as the baseline year, The AbarisGroup calculated projections to fiscal yearusing the assumptions of a nine percentper year cost increase and a seven percentnet revenue increase. This cost assump-tion is justified due to the higher pastmedical cost index increases in San Diego,recent past higher costs of labor (e.g.staffing registries and new labor contracts)and the overall high technology increasesprevalent in health and trauma care.Revenue assumptions were deemedaggressive but necessary to achieve areasonable period of cost recovery. Evenso, these revenue assumptions need to becarefully monitored in light of anticipatedreductions in Medicare and MediCalrevenue and the increasing inability ofhospitals to get full cost recovery fromother payers. It is also recognized in thehealthcare industry that a positive marginof at least six percent is needed for mosthealth product lines to survive to assurestability and that a contribution is made tofuture capital needs.

Assumptions, baseline and projectedrevenue and cost calculations were sharedand approved by each trauma center. TheAbaris Group trauma volume projectionswere also used for the financial projec-tions. The Abaris Group included futuretrauma care and SB12/612 funding as partof each trauma center’s net revenue for theperiod of time predicted.

Results

Exhibit 42 shows a composite of thefinancial performance of San DiegoCounty’s trauma centers. The net result isan actual gain in 202 of $16.9 million but aprojected loss beginning in 2006 and asteady decline over the next four years to a$7.7 million. This is due to increasingcosts and the inability of revenue to keeppace with the costs. The picture in San

three use October to September fiscalyears. These variations in fiscal year timingwere not considered by The Abaris Groupto be a problem as there should be consis-


Diego is consistent with other studiedtrauma centers with typically wide shifts inrevenue/costs based on acuity of patientsand length of stay and the shifting of thevery fragile payment system upon whichtrauma centers exist.

Actual Estimate Estimate Estimate Estimate EstimateFY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007

VolumeTrauma Cases 9,516 9,923 10,322 10,742 11,186 11,653 Percent Change - 4.3% 4.0% 4.1% 4.1% 4.2%

Net Revenue Patient Revenue $127,513,873 $137,540,565 $153,691,744 $171,811,608 $192,173,047 $215,002,284 Trauma Care Funding1 4,852,537 2,660,452 - - - - Maddy, SB12/612 Funds1

207,012 307,790 307,790 119,216 119,216 119,216 Total Revenue 132,573,422 140,508,807 153,999,534 171,930,824 192,292,263 215,121,500 Percent Change - 6.0% 9.6% 11.6% 11.8% 11.9%

ExpensesTotal Expenses 115,644,269 132,188,831 150,505,751 171,433,495 195,386,468 222,771,553

Percent Change - 14.3% 13.9% 13.9% 14.0% 14.0%

Net Operating Income 16,929,154 8,319,976 3,493,783 497,328 (3,094,205) (7,650,053) Percent Change - -50.9% -58.0% -85.8% -722.2% -147.2%

Margin 14.6% 6.3% 2.3% 0.3% -1.6% -3.4%

1Assumes trauma care funding for FY02 and FY03, SB12/612 funds provided for FY02 to FY07 and Maddy Fund for FY02-04.

Source: Cost and revenue data provided by five trauma centers using their FY02 and extrapolated for one trauma center using their FY01. Cost and revenue per patient reported by hospitals were applied to volume reported by SDEMSA for FY02 (Jul - Jun).

Summary of All San Diego County Trauma CentersTrauma Center Financial Projections


Additional San Diego County Trauma Maps

The following series of maps were generated using map files from SANDAG and data fromthe San Diego County EMS Agency. These maps provide support to the population, road-way and trauma volume commentary provided in this report.

Four trauma centers, Scripps Mercy, Sharp, Children’s and UCSD, are in close proximity toone another in the central region of San Diego. Scripps La Jolla is north of the cluster, whilePalomar is located much farther north along Interstate 15.

Source: SANDAG, SDEMSA

I - 805

Inte

rsta

te 1

5

Interstate 8

Highway 67Highway 67Highway 67Highway 67Highway 67Highway 67Highway 67Highway 67Highway 67

Highway 94

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Major Roadways

(((((((((((((((((((((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((

(((((((((((((((((((((((((((((((((((((((((((((((((

Palomar MC

Scripps La Jolla


Scripps MercyUCSD

Exhibit 43 - Location of Trauma Centers andMajor Roadways


The only trauma volume data available on a smaller geographic level (i.e., smaller thanthe trauma center’s catchment area) is from the SDEMSA Prehospital Database. Themost recent time period available is June 1999 through July 2000 (FY00). It is impor-tant to note that data in the Prehospital Database are only trauma transports. Transportsdo not include those trauma patients who were transferred from another hospital,brought to the trauma center in a private vehicle or upgraded to trauma status from theED. In addition, although there are a total of 6,445 trauma transports in the database,only 6,113 were assigned a geographic identifier.

Catchment Boundary

15

69

38

131

4972

150

23

25

20

407

45

100

65

111

53

142

65

214

103

48

336

290

52 162

185

145133

1195

281

410122

492

612

101

124

41

164

304

108





Exhibit 44 - The Number of Trauma Cases bySRA

The above map depicts the trauma volume by SRA (subregional area) within eachtrauma center’s catchment area. The following table shows the EMS transport volumefor each trauma center.

Exhibit 45 - Trauma Center EMS Transport Volume

Trauma Center Volume, FY00

Children's 774 Palomar 726 Scripps La Jolla 961 Scripps Mercy 1,274 Sharp 1,204 UCSD 1,174 Source: SDEMSA Prehospital Database FY00, n=6,113


The 2000 population of San Diego County was 2,813,833. The SRAs in the eastern part of thecounty have a lower population density, while those in the western region are much moredensely populated. Palomar and Sharp have the largest square mile catchment areas. How-ever, several of the SRAs within their catchment areas are sparsely populated. The otherhospitals are located in areas with more densely populated SRAs.

Exhibit 46 - Population Density by SRA

Source: SANDAG, 2000 Census

Catchment Boundary





Palomar MC

Scripps MercyUCSD


Scripps La Jolla

Population Density by SRA2000 Census (People/Sq. Mi.)

6,000 to 10,2002,500 to 5,999

500 to 2,499100 to 499

0 to 99


According to SANDAG, the projected population growth rate for San Diego County from2000 to 2010 will be an average of 1.4 percent per year. SRAs that are projected to growsignificantly (adding 30,000 – 70,000 people by 2010) are in the Chula Vista area and theDel Mar-Mira Mesa area. Other SRAs that are projected to grow (adding 15,000 – 29,999people by 2010) include the areas around Escondido, San Marcos, Carlsbad, Oceanside,and central San Diego. SANDAG population projections show the east county region tobe an area with comparatively little growth in the next 10 years (less than 1,000 to 4,999people by 2010).

Catchment Boundary

Coronado

Chula Vista

Lemon Grove

La Mesa

El Cahon

SanteeSan Diego

Del Mar

Solana Beach

Encinitas

Poway

EscondidoSan MarcosCarlsbad

Vista

Oceanside

Sharp Mem.

UCSD

Children's

Mercy

Scripps La Jolla

Palomar MC

Projected Pop. Growth by SRA2000 to 2010

30,000 to 70,00015,000 to 29,9995,000 to 14,9991,000 to 4,999

Less than 1000 people

Exhibit 47 - Projected Population Growth bySRA for 2000 to 2010

Source: SANDAG, Preliminary Projections, Released October 2002


The SRAs with the greatest density of trauma cases (18 to 26 cases per square mile) are inthe Scripps Mercy and UCSD catchment areas. Those SRAs with 10 to 17 cases per squaremile are mostly located in the Sharp, Scripps La Jolla, Scripps Mercy and UCSD catchmentareas.

Exhibit 48 - Trauma Rate per Square Mile bySRA


Catchment Boundary





Palomar MC

Scripps MercyUCSD


Scripps La Jolla

Trauma Rate (cases per Sq. mile)by SRA

18 to 2610 to 175 to 91 to 4

Less than 1


Pediatric (0 – 14 years of age) trauma cases in the county are treated at Children’s. Theincidence of pediatric trauma is highest in the central region of San Diego.

Catchment Area


Mercy Catchment AreaUCSD Catchment Area



Palomar MC

Scripps MercyUCSD


Scripps La Jolla

Pediatric Trauma Volumeby SRA (age 0 - 14)

50 to 6425 to 4915 to 24

5 to 140 to 4

Exhibit 49 - Pediatric Trauma Volume (Aged 0 -14) by SRA



This map uses both thematic characteristics and elevation to depict trauma volume bycatchment area. The second view is from the North County border, providing a dramaticview of the trauma volume.


Trauma Volume by SRA

> Than 300 cases

Between 150 & 300

Between 75 & 150

Between 25 & 75

Between 11 & 25

Exhibit 50 - 3-D Illustration of Trauma VolumeSRA With Catchment Areas


This map illustrates the current catchment areas for the trauma centers and the changesproposed by the San Diego City Fire Department. Proposed changes to the existingcatchment zones only occur in the core area of San Diego and are minimal. Using thetransport data provided by QANet, The Abaris Group was able to estimate the changesin volume for those catchment areas impacted by the change. UCSD would lose 3square miles and approximately 40-50 cases, Sharp would gain approximately 4 squaremiles and 70 – 80 cases, and Scripps La Jolla would lose approximately 4 square milesand 70 – 80 cases.

Current Catchment Boundary

Proposed byCity

Current CatchmentAreas

Sharp Mem.

Children's

Scripps MercyUCSD

Palomar MC

Scripps La Jolla

Exhibit 51 - Proposed Trauma Catchment Areasby San Diego City Fire Department

Source: SANDAG and the San Diego City Fire Department


The Abaris Group completed an analysis of the impact on configuration of the San DiegoCounty trauma system if one or two trauma centers dropped out of the system. FY00Prehospital Database for EMS transports was used as the base line (this being the mostcurrent smaller level geographic data available). The Abaris Group staff followed majorroadways and freeways in redrawing the boundaries. Each SRA was reviewed and allo-cated to the appropriate suggested catchment. Those SRAs that straddled a boundarywere allocated to the suggested catchment areas proportionately, based upon thepercentage of the SRA that fell in each catchment area. The trauma volume for the SRAwas then distributed to the catchment area according to that percentage. Finally, TheAbaris Group staff calculated a multiplier to apply to each SRA to increase the EMStransport numbers to the more appropriate trauma arrivals figure. Pediatric volume isaccounted for in each catchment’s total trauma count.

This map illustrates a possible revision to the trauma catchment areas if one traumacenter dropped out of the system.

Catchment 1Volume 2628

I - 805

Inte

rsta

te 1

5

Interstate 8

Highway 67

Highway 94

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Major Roadways

Catchment 1Trauma Count = 2628




Exhibit 52 - Effect of One Trauma CenterLeaving the San Diego County Trauma System

Source: SANDAG, SDEMSA and The Abaris Group


This map shows what the catchment areas might look like if two hospitals dropped out ofthe San Diego County trauma system. Obviously, the estimated trauma volume at theremaining centers reaches overwhelming proportions. The trauma transport numberswere obtained from the FY00 Prehospital Database and then proportionately adjusted toreflect trauma arrivals.

I - 805

Inte

rsta

te 1

5

Interstate 8

Highway 67

Highway 94

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Highway 79

Major Roadways


Catchment 2Trauma Volume = 2717

Catchment 3Trauma Volume = 2578

Exhibit 53 - Effect of Two Trauma CentersLeaving the San Diego County Trauma System

Source: SANDAG, SDEMSA and The Abaris Group


Population-Based TraumaStudy

The Abaris Group analyzed hospital dis-charges by injury severity score (ISS) scoreusing ICDMAP-90 software. This methodhas been described by MacKenzie andvalidated in the literature as a tool toinvestigate trauma system from a popula-tion standpoint.44 This method useshospital discharge data ICD codes to mapto injury severity scores (ISS). While themethod is not perfect, it is a way forconducting population studies on traumacase destination and severity. The MacKen-zie study confirmed that there was areasonable match using the ICDMap-90software to actual chart coding.

Patient discharge data was obtained fromthe Office of Statewide Health Planning andDevelopment (OSHPD) California PatientDischarge Data for 2000. The OSHPD datawere uniquely identified for each patient,thus eliminating double counting. TheICDMAP-90 software was developed by theCenter for Injury Research & Policy of theJohns Hopkins University Bloomberg Schoolof Public Health. ICDMAP-90 translates theICD-9 injury codes from the OSHPD inpa-tient discharge data into an ISS score forhospital.

A total of 5,794 patients had an ISS of 9 orgreater, of which 3,561 (61.5 percent) weretreated at trauma centers. 85 percent of themajor trauma, or those patients with an ISSscore greater than 15, were treated at traumacenter facilities.

Careful use of this data is important. Thedata come from discharge data and includepatients from EMS transports who mayhave or may not have initially met trauma

center standards but subsequently weredischarged with ICD codes that mappedwith a 9 or greater ISS. Some of thesepatients may have had injuries so severe(e.g. respiratory arrest) that the traumapatient could not be transported to atrauma center. Some of these patients mayhave been transported to the non-traumacenter by private vehicle. The computermodel may not also control for other injuryconditions that mimic trauma centerpatients (e.g. a patient with a high ISSscore but that did not meet the traumacenter criteria such as an elderly hipfacture). However, there is the potential forthis data to demonstrate some level ofunder-triage and the data may be useful tofurther triage studies as well.

A review of this data compared to othertrauma discharge data studies demon-strated excellent capture by the traumacenters for trauma patients. A comparisonof this data to a previous study conductedby Dr. John Udell, Trauma Coordinator, Stateof New Mexico, indicates that this 2000 yeardata closely matches his 1998 San Diegodata and other better practice traumasystems in the country. Dr. Udell has con-ducted 40 of these discharge dataset studiesnationwide.

44 MacKenzie EJ, Steinwachs DM, Shankar B. Classifying Trauma Severity Based on Hospital Discharge Diagnoses: Validation of an ICD-9CM to AIS-85 Conversion

Table. Med Care 1989 Apr;27(4):412-22.


Exhibit 54 - Distribution of Trauma AmongHospitals

San Diego Hospitals

ModerateTrauma

ICD-ISS 9 to 15Percent of

ModerateMajor Trauma

ICD-ISS > 15Percent of

MajorFacility

TotalPercent of

TotalNon Trauma Centers Mesa Vista Hospital - 0.0% - 0.0% - 0.0% Villa View Community Hospital 5 0.1% - 0.0% 5 0.1% Scripps Hospital - East County 21 0.5% 1 0.1% 22 0.4% Sharp Coronado Hospital & Healthcare Ctr 39 0.9% 9 0.6% 48 0.8% UCSD/La Jolla - Thornton Hospital 51 1.2% 2 0.1% 53 0.9% Paradise Valley Hospital 65 1.5% 7 0.5% 72 1.2% Scripps Memorial Hospital - Chula Vista 69 1.6% 7 0.5% 76 1.3% Sharp Cabrillo Hospital 69 1.6% 9 0.6% 78 1.3% Fallbrook Hospital District 73 1.7% 4 0.3% 77 1.3% Scripps Memorial Hospital - Encinitas 91 2.1% 10 0.7% 101 1.7% Sharp Chula Vista Medical Center 100 2.3% 12 0.8% 112 1.9% Scripps Green Hospital 118 2.7% 12 0.8% 130 2.2% Pomerado Hospital 163 3.7% 8 0.6% 171 3.0% Alvarado Hospital Medical Center 182 4.2% 25 1.7% 207 3.6% Grossmont Hospital 232 5.3% 30 2.1% 262 4.5% Tri-City Medical Center 365 8.4% 32 2.2% 397 6.9% Kaiser Foundation Hosp - San Diego 377 8.7% 45 3.1% 422 7.3%Non Trauma Centers Sub Total 2,020 46.4% 213 14.8% 2,233 38.5%Trauma Centers Children's Hospital - San Diego 203 4.7% 129 9.0% 332 5.7% Palomar Medical Center 441 10.1% 206 14.3% 647 11.2% Scripps Mercy Hospital 434 10.0% 219 15.2% 653 11.3% Scripps Memorial Hospital - La Jolla 382 8.8% 255 17.7% 637 11.0% Sharp Memorial Hospital 524 12.0% 216 15.0% 740 12.8% UCSD 350 8.0% 202 14.0% 552 9.5%Trauma Centers Sub Total 2,334 53.6% 1,227 85.2% 3,561 61.5%Grand Total 4,354 - 1,440 - 5,794 -

Moderate to Major Trauma Distribution for San Diego County Hospitals(based on ICDMAP-90 ISS calculations)

Source: OSHPD California Patient Discharge Data,2000 & ICDMAP-90 Software, Center for Injury Research & Policy of the Johns Hopkins University Bloomberg School of Public Health.


Trauma Center FundingComparison Study

Introduction

Providing a stable source of funding fortrauma centers has been an ongoing issuesince the early development of traumasystems in the country. Changes in fundingsources, particularly insurance payers, havecreated instability over the years.45, 46, 47

Improving revenue cycle management andpayer contracting has helped, but in somecommunities these efforts have not beensubstantial enough to stabilize their traumasystem.

In this section, The Abaris Group providesan overview of identified funding sourcesfor trauma care.

State Funding Sources

Many states provide funding for theadministration of their state’s traumasystem at the state level. However, thereare only four states that provide ongoingfunding to support their trauma centers:Illinois, Mississippi, Oklahoma, andWashington. California has a one timefunding program that expires in 2003.

Arizona

During November 2002 the state voted toapprove doubling the state’s tobacco taxon cigarettes to $1.18 a pack and use the$150 million strictly for the trauma cen-ters. The measure passed two to one. Thedetails on the expenditures are still beingworked out in the state.

California

During the 2001 legislative session, theCalifornia Legislature passed AB1430, The

Trauma Fund Act, which encouraged thedevelopment of a statewide network oftrauma centers and established a one timesource of funds for trauma centers in thestate. The $20 million allocated from thisbill was renewed during 2002 and willprovide support to the trauma centersthrough 2003. The funding is allocated on afixed and volume basis. Each trauma centerreceived a fixed amount according to theirdesignation level (e.g. $150,000) and thenan allocation based on volume of patientsas determined by the trauma registryentries. San Diego County trauma centersreceived $4.9 million for FY 2002 and willreceive another $2.7 million for FY 2003.

Illinois

The State of Illinois established a fund foruncompensated trauma care in 1993. Thefunding derives comes from a $5 feeplaced on every moving violation over $55.In 1994 a $30 fine from each DUI convic-tion or order of suspension was added.Since 1993, they have expended approxi-mately $20.4 million. The amount offunding each hospital receives depends onthe number of trauma patients treated.Additionally, funding is provided to thosehospitals that care for Medicaid traumapatients. There is no funding for physi-cians.

Mississippi

In 1998 the State of Mississippi beganallocating between $8.0 – 8.5 million annu-ally for uncompensated trauma care. Thefunds come from revenue generated byMississippi’s Tobacco Settlement principal($6.0 million) and from moving trafficviolations ($2.5 million). There are seventrauma regions, each receiving $85,000thousand for administration purposes. Theremaining portion is divided amongparticipating hospitals and surgeons

45 Trauma Care: Saving Lives Despite Setbacks, Zoller, M. Medical World News, June 1988.46 Trauma Collapse, Can the system be saved?, Williams, MJ. California Hospitals, October 1999.47 Trauma Care: “Lifesaving System Threatened by Unreimbursed Costs and Other Factors”, GAO, May 1991.


(orthopedic, general and neuro). In addi-tion, Level IV trauma centers that transfera trauma patient also receive 20 percent ofthe reimbursable amount. In order toreceive compensation, the patient mustmeet the trauma criteria and not have anyability to pay the charges.

Oklahoma

The State of Oklahoma’s uncompensatedtrauma care fund was established in 1999. Itis generated from a $1 per person driver’slicense renewal fee. The fund’s balance is$2.6 million, with 10 percent going to theDepartment of Health for administration ofthe trauma system and the remainderdivided among trauma centers andprehospital providers. There is no compen-sation for physicians.

Washington

In 1997 the State of Washington passed alaw creating the Trauma Fund to providefunding for uncompensated trauma care.The Trauma Fund expends approximately$31.0 million every two years. The funds aregenerated from a surcharge on motorvehicle infractions ($5 of every fine) and thelicensing of new and used vehicles ($4 pervehicle). The sources generate roughly $30million annually. The remaining $8.0 millioncomes from federal Medicaid matchingfunds. To qualify for reimbursement thepatient must have an Injury Severity Score(ISS) of 9 or greater and be eligible formedical assistance (Medicaid). The Stateprovides funding for prehospital providers,hospitals, physicians and rehabilitationfacilities. The state hired Arthur Anderson in1992 to help them determine the level ofuncompensated care. Washington has arelatively stable state trauma fund. Somefunds go to trauma centers, with extragoing to those treating DHS patients(through participation grants), plus addi-tional reimbursement for patients with aspecific ISS.

Other Public Funding

Alameda County, CA

Alameda County has a special EMS andtrauma tax district called the AlamedaCounty EMS District. It was formed in themid 1980s to support EMS providers andto develop the trauma system. The fundassesses all parcels at $23.94 per parcel.The trauma portion of that equates toabout $8 per parcel. The fund wasestablished for the EMS Agency, EMSproviders and the trauma centers (2 adultand 1 pediatric trauma centers). Thetrauma centers are subsidizedapproximately $10 million per year basedon uncompensated care. The tax wasdeveloped under the Special BenefitAssessment District law of California thatallowed the Board of Supervisors or theelectorate to provide a simple majority forapproval of these assessments. TheCounty chose to obtain voter approval, andit was approved by in excess of 80 percentof the voters. When the BenefitAssessment statute was overturned fiveyears ago, the Tax District was re-voted onwith another landslide approvalpercentage. The EMS Agency is called “TheEMS District” and it controls all fundswhich have been authorized for theDistrict. (San Diego has approximately885,000 parcels. A similar trauma tax at $8per parcel would generate approximately$7.1 million per year. )

Los Angeles County, CA

Los Angeles County has funded traumacenters for nearly 15 years through a combi-nation of general fund and tobacco taxfunds. The reduction of tobacco tax dollarsover recent years put the trauma network incrises and that plus serious County budgetshortfalls put the entire Los AngelesCounty public hospital system at risk. Aballot measure introduced to provide for$168 million in funding was approved by a73 percent vote in November 2002. Mea-


sure B raised property taxes by three cents,or about $42 for a 1,400 square foot home.In addition to funding trauma centers andemergency departments the money wasproposed to be used for bio-terrorism. Thefunding is going to be heavily used tostave off the closing of Harbor-UCLAMedical Center, a Level I trauma center,and Olive View-UCLA Medical Center, anacute care hospital. There is some hopethat these funds will help entice hospitalsthat used to be trauma centers in thePomona and Antelope Valleys to comeback in as trauma centers. There are threepublic (LA County Department of Health)and ten private trauma centers in thecounty. It is not clear how much of thesefunds will be available to support theprivate trauma centers once the publichospital needs are met. This was the firstcountywide increase in property taxes inLos Angeles County since 1978.

Palm Beach County, FL

The Palm Beach County, Florida fundingmechanism is an independent taxing districtauthorized through the state for Palm BeachCounty. The tax district charges a propertytax of about $1 per $1,000 assessed value. Itgenerates over $100 million in revenueannually, with $24 million budgeted fortrauma. The remaining funds go to otherindigent care, school nurses in the publicschools, etc. Of the $24 million budgeted fortrauma, two trauma centers each receive $6million per year, with on-call physiciansreceiving about $8 million and an airmedical program taking up the balance.Funding to the hospitals has remainedfairly static. The funds had been allocatedto the trauma hospitals in grants, butcurrently the County is using a formulabased on percentage of uncompensatedcharges. In addition to paying for on-callcoverage, the fund also pays some mal-practice insurance costs for the traumaphysicians.

Other Initiatives

There are other trauma funding tax activi-ties in Florida. Dade County uses a halfcent sales tax to fund their one traumacenter. Broward County has two taxingdistricts for funding indigent care includ-ing the indigent care for trauma centerpatients. The tax revenue goes to reim-bursing hospitals and their physicians fortrauma care at Medicare rates. Lee County,FL authorities proposed a trauma centersales tax to raise $35 million for theirsingle trauma center and multiple emer-gency departments but the initiative failed.Five million was earmarked for the traumacenter. 57 percent of the voters votedagainst the measure.

San Diego County has electively chosen toprioritize the use funds from traffic finesurcharges (SB12/612) and other sources(Maddy Fund) to support the trauma cen-ters. The total annual allocation from thesefunds ranges from $120,000 to $300,000per year depending on revenue from thefunds.

California has under taken several otheremergency department and trauma centerfunding activities. Approximately one yearago Senator Gloria Romero (D-Los Ange-les) proposed a “nickel a drink” tax(SB108) to support the emergency depart-ments and trauma systems in the state.This bill would provide a fund to pay forexpenses for “alcohol-related” emergencyroom and trauma center care. The bill hasbeen heard at the state level several timesbut is not expected to move quickly due toState budget constraints. During February2003, the Los Angeles County Board ofSupervisors voted to ask the State Legisla-ture for permission to levy a similaralcohol tax in the county. A CaliforniaMedical Society and California HealthcareAssociation initiative two years ago,designed to develop a ballot measure tofund the emergency department andtrauma center network in the state failed to


achieve sufficient voter interest to justifycontinued pursuit by these organizations.

Other Potential Sources

Existing General Revenue and/orFederal Funds

Consideration has been given by some fordirect funding for the state’s trauma centernetwork through existing general revenue.Los Angeles has provided modest fundingfor their trauma centers through theirgeneral fund but has indicated this fundingcannot continue. There is no county budgetin California that is not significantly strainedand capable of allocating significant fundsfor new purposes such as the traumanetworks in their communities.

Surcharges

Another approach would entail increasingor adding surcharges or fees to productsor activities that frequently contribute tothe need for trauma care services. Consid-eration of adding additional surcharges fortraffic fines is a challenge in the state asthe courts levying such fines have indicatedthey are not willing to add to the surchargesor to see those funds go outside the crimi-nal justice system.

Some states (Oregon, Washington) haveattached surcharges to the fee for eachmotor vehicle license registration issuedin the state, including motorcycles. Auto-mobile collisions are growing as thenumber of miles traveled annually in-creases. Similar proposals in other stateshave added a $5 surcharge on motorvehicle registrations, with estimates thatthis would generate an estimated $100 to$150 million per year. Another source inCalifornia would be to increase the fee fordriver license/ID issuance and renewal.This concept is similar to the vehiclelicense fee and would be to increase thefee to obtain or renew an identificationand/or a license to operate a motor ve-

hicle, including motorcycles. The chal-lenge to this concept is that it is alreadybeing pursued in the State budget as afunding measure to close the budget gap.Another option is to establish a surchargeto automobile insurance policies. Consideradding a surcharge on each automobileinsurance policy issued in California.Pennsylvania has implemented this ap-proach to supplement funding. There isthe concern of insurance companiessupporting an addition to the alreadyexpensive insurance premiums in Califor-nia. Another consideration is to requireautomobile insurance policies to provide$50,000 in personal injury protection fortrauma care, with the auto policy coveragepaying the trauma center costs first, andhealth insurance being a secondary payer.This is common practice in some states(Connecticut and Oregon) with higher thanaverage health coverage on their autopolicies and state statutes that require theauto insurance policy to be the first sourceof payment for auto collision injuries.

Another option is to provide an assess-ment on the illegal discharge and/or saleof firearms and ammunition. The State ofIllinois has in the past introduced legisla-tion to levy a fine on the illegal dischargeof firearms and add a tax to the sale offirearms, which in 1997 would have re-sulted in $5 million in annual revenue.Such fines and taxes were proposed in aneffort to offset trauma costs associatedwith violent crimes. There is a significantgun lobby that would need to be overcomefor this concept to be successful.

Another concept would be to add to the 9-1-1 surcharge on phone bills in the state.This is a potent revenue source as thenumber of telephone lines and cell phonesin the state is increasing rapidly. There iscurrently a surcharge on telephone bills tofund the 9-1-1 system. This approach hasbeen attempted in California a number oftimes and has been rejected due to signifi-cant public safety concerns of the inappro-priate use of the 9-1-1 surcharge for nonpublic safety reasons.


V. Conclusions andRecommendations

Acute Trauma Care

The six trauma centers provide the bulk ofthe acute care delivery system in the countyand are really the center of excellence for thetrauma system. The Abaris Group’s reviewof the trauma centers concluded that thetrauma centers operate at a best-practicelevel with respect to their capabilities,commitment and unrelenting focus onquality. The commitment alone is worthmentioning, as it permeates the executiveleadership, medical staff and trauma careproviders.

The quality of trauma care and execution ofthe function of trauma center supervisionat the County level are both exceptional.The community of San Diego should becomforted and proud of their industry-leading trauma delivery system. Traumacenter operations exhibit their quality as afunction of the above factors and thededication and resources of the traumamanagement team.

There are no significant immediate recom-mendations for trauma acute care or forthe trauma center criteria. Two modestrecommendations are made as follows:

§ Trauma Program Manager Position. Itwas noted by The Abaris Group thatthe trauma program manager positionis not consistently staffed at a full-timetrauma manager level at each traumacenter. There have been times whenthis has been a rate-limiting factor forthe trauma system. The Abaris Grouprecommends that the County establishthe trauma program manager positionas a full-time requirement within thetrauma center standards.

§ Trauma Physician Staffing. The traumacenters will continue to be challengedwith trauma physician staffing issues

fueled by the limited number of physi-cians, declining interests in servingtrauma centers and EDs and physicianlife-style needs. The trauma centersmust work individually and collectivelyto identify future needs and matchthose needs to creative strategies.These strategies may include adjust-ments to the triage standards, im-proved control of non-trauma patientconsultative transfers to the traumacenters, care pathways at the traumacenters to reduce unnecessary utiliza-tion of key specialists and developingways to leverage the skills of otherpractitioners to reduce key specialistworkload (e.g. nurse practitioners,specialized hospitalist programs, etc).

“The Abaris Group’s

review of the trauma

centers concluded that

the trauma centers

operate at a best-

practice level with

respect to their

capabilities, commit-

ment and unrelenting

focus on quality.”


Trauma Quality Improve-ment

Without question, the trauma qualityreview process is the single most impor-tant strength of the trauma system andmany positive conclusions have beendrawn in this report about this process. Asin any complex and resource-intensiveprocess of integrity, there are opportunitiesfor refinement. Although the quality reviewprocess has been refined from its initialburdensome formula, it cannot be called atrue quality improvement process, butrather a medical audit or event process.Much of the work of MAC verifies the highlevel of clinical performance of the SanDiego trauma centers but verifies little ofthe overall exceptional operational, costand system performances which wereevident during The Abaris Group traumacenter reviews. In addition, there is littlejustification to continue some portions ofthis process which yield scant returns andthere is much to be gained by efforts in thelatter mentioned areas.

There is a role for both event and processcomponents in a quality improvementeffort for a mature trauma system such asSan Diego. An important feature of theMAC process, the collegial atmosphereand relationships which exist among thetrauma centers, should not be lost in anyfine tuning of the MAC process. In addi-tion, all modifications should serve tostrengthen the hospital/County partner-ship.

Some suggested refinements in-c lude:

§ Outlier Review. Discontinue circulationof “non-outliers” during the Pre-MACprocess, thereby reducing the timeburden on the trauma directors. Thetrauma medical directors should beencouraged to include dictation oncases of interest or those havingparticular educational merit.

§ System Data. Begin to consider spe-cific system issues derived from theCounty data set. Any trauma centershould be able to request trended dataon given injuries, injury mechanisms,prehospital protocols and the likewithout complex approval processesand access issues.

§ Benchmarks. The potential to createbenchmarks is a supportable activity.This can be accomplished on clinical,process, and financial topics. Sharingthe data between trauma centers wouldalso create healthy competition. Thisalone may be an effective way to lever-age performance review.

§ Prehospital. Methods to close the gapbetween the trauma system andprehospital system should be initiated. Aquarterly educational forum, open toprehospital and hospital participants,could be developed and cases of meritfrom MAC could be presented in a grandrounds format. This might be titled the“San Diego County Trauma Rounds.”This would involve a larger group ofstakeholders (larger than MAC partici-pants) and might include noteworthycases, pitfalls in triage decision mak-ing, etc., but would allow a wideraudience to be exposed to the excel-lence in care. It would dovetail nicelywith a marketing recommendation topromote the trauma system, which ismade later in these recommendations.This could also force a system-widefocus on the care of the patient fromresponse, field care, resuscitation,hospital care, etc. It would also pro-vide an opportunity for enhancedrelationships among hospitals andprehospital agencies and provide atleast one additional mechanism forfeedback to prehospital providers. TheCounty could be asked to provide dataon the system’s performance based onsystem audit filters. This would requirea more current data management

“There is a role for

both event and process

components in a

quality improvement

effort for a mature

trauma system such

as San Diego.”


system and process. It would allow theMAC participants to utilize theirknowledge to trend issues and improvethe system in the same way they refineand improve their trauma services andclinical care approaches.

§ Strategic Initiatives. There are impor-tant trended and strategic consider-ations for the San Diego traumasystem. More strategic emphasisshould be placed on a system perfor-mance review process with MAC in aleadership position for that role.Through strategic planning, the traumacommunity would begin to identifysystem trends and needs that shouldbe studied and developed through theMAC process. These might includecare pathways, cost reduction efforts,improved system coordination, im-proved efficiency and integrity of thedata collection process, triage andoutcome studies, strategic planningfor volume changes, scenarios forresource changes (e.g. number oforthopedic surgeons), and system-wide changes (e.g. if a trauma centerterminated their designation) andother issues of system-wide signifi-cance that are largely not exploredtoday. This would slightly alter MAC’srole from nearly 100 percent event-based review to a balance of event andsystem issues, but it would bring thequality review process more in-linewith contemporary process improve-ment practices.

§ Data Security and Reporting. Initiativesshould be developed to build a higherconfidence level with the EMS Agency,its data acquisition, security andappropriate work on system reportingand trending. For example, the EMSAgency should explain the securitymeasures they follow to protect thePre-MAC binders. There are significantdelays in achieving trauma reportingdue to certain practices and policies at

the trauma center and County levels. Afull exploration of this issue is needed.

§ Annual Trauma Center Audit. TheAbaris Group recommends moving thecomprehensive annual audit to everythree years. The current annual audit isresource-intensive and does not appearto create substantial yield. The Countyis also experimenting with a self-reported audit this year. The three-yearACS review is an important ongoingvehicle for quality review and shouldnot be abandoned. It is thereforerecommended that the trauma centerscontinue their EMS Agency reviewprocess but that it be annual and selfreporting and the onsite EMS Agencyaudit portion be blended into a three-year ACS review.

§ EMS Agency Review. The EMS Agencyshould also be subject to a three-yearreview that connects to the approvedvision, deliverables and other traumasystem expectations collaborativelydeveloped as part of the strategicinitiative process.

§ Trauma Designation Fees. The AbarisGroup recommends eliminating thetrauma center designation fee as agesture of good faith to further thetrauma system partnership as de-scribed under Leadership below.Trauma system stakeholders shouldlook to assisting the County in reduc-ing or offsetting their costs by support-ing the reducing audit role, reducingunnecessary work on the traumaregistry (redundant verifications) andreduction of their duplicative roles atPre-MAC and MAC.


Trauma Triage

San Diego’s trauma triage standardsfollow national criteria but have not beencomprehensively studied and customizedfor local conditions, resource consumptionand patient outcome. The San Diegotrauma system faces numerous challengesto its financial viability and a high rate ofover-triage may be taxing the resources ofthe system. While not apparent in SanDiego, some communities with non-trauma hospitals perceive that high ratesof over-triage threatens their viability aswell. The widening funding gap for traumasystems will eventually require an align-ment of appropriate resources for appro-priate patients.

§ Quantitative Analysis. The San Diegotrauma system should conduct aquantitative analysis of its traumatriage criteria using the rigors of apublishable study. The clinical, finan-cial and legal implications of a traumasystem make it important for a thor-ough quantitative examination of theeffects and impact of triage policieswithin a given trauma system. SanDiego’s trauma system has the datacollection capability, if properly linked,to conduct such a study.

§ Patient Definition. As this reportdocuments, there are significantlimitations to the patient definitionsused in current San Diego data sources(QANet, the Trauma Registry, andhospital discharge data). The registryor any special study database willrequire more inclusive criteria toassure ED discharges and other traumapatients are properly studied as part ofthe triage analysis.

§ Linked Databases. The ability to linkfield and trauma registry data existsbut is not currently used to the extentthat it could be useful to a triage study.This linkage and compliance with data

entry should be established for thetriage study.

§ Triage Decision Points. The decision-making process cannot be verifiedalong the points of the care continuumas there is no documentation of thecriterion used to make triage deci-sions. There should be clear delinea-tions of the trigger criteria for definingtrauma patients and this documenta-tion should be included in the prehos-pital care data and with the QANet.

“The San Diego

trauma system should

conduct a quantita-

tive analysis of its

trauma triage criteria

using the rigors of a

publishable study.”


Trauma Prevention

Injury prevention is a high priority for theSan Diego community and the traumanetwork. There are, however, opportunitiesto refine and to more clearly target traumasystem prevention priorities. Traumaprevention recommendations are asfollows:

§ Injury Prevention Clearinghouse. SanDiego should develop an injury preven-tion center/clearinghouse that workscollaboratively with the trauma centersand community organizations. Oneentity that would lend itself to this roleis TREF. The clearinghouse could serveas a neutral recipient of grants andoperate as an information resource forinjury prevention information, pro-grams, and assistance to the traumacenters. This clearinghouse shouldalso identify opportunities for improv-ing communication on all injuryprevention programs. For example,establishing a web site in collaborationwith the trauma centers and otheragencies providing injury preventionprograms would be a valuable re-source. TREF has an existing web sitethat might be a possible springboardtoward achieving this goal.

§ Trauma System Prevention Targets. Topursue the goal of targeted traumasystem prevention, it is important forthe “system” to agree that one or moreprevention programs should be drivenbased on trauma patient epidemiologyeither from the standpoint of targetedhigh-risk patients or yield. This wouldinclude conducting an annual evalua-tion of the trauma system data in orderto identify trauma center trends withinthe community and coming to consen-sus on the targets. The County EMSAgency should take the lead on thisidentification process.

§ Targeted Program Implementation.Implementing trauma system programsdriven by registry data may create ayield for existing programs that aremodified for that targeted purpose ornew programs that could be created.The key is global trauma systemparticipation. TREF continues to be anobvious source for this implementa-tion effort.

§ Funding Sources. Identifying a stableand secure funding source for traumasystem injury prevention is a likelyactivity to be directed to TREF and theSan Diego County EMS Agency tosupport the functions listed above.


Trauma Registry

Significant emphasis is placed in the SanDiego trauma system on data collectionand data integrity. While there arestrengths to the current San Diego traumaregistry system, there are roadblocks tomaking it the most effective and efficientinformation system for the future. Therecommendations on the trauma registryare as follows:

§ Creation/Acquisition of a Single Ro-bust Trauma Registry. The AbarisGroup finds there are major limitationswith the use of two registries in acontemporary trauma system. Clearlythe Dales Registry has provided a highquality product for many years to thetrauma system. Not unlike theCounty’s bubble form, the registry haslimitations and lacks the capability tointegrate with other informationsystems and complete the requiredreporting functions that will be neces-sary for a contemporary trauma systemin the future. There is also the ongoingwork at the County level and at thevarious trauma centers in “making thesoftware work” as it relates to report-ing and the interfaces required tointegrate the two databases. The DalesRegistry by definition is an agingproduct without clear indication that itwill have the resources to undertakewhat will eventually be a necessarysignificant overhaul.

§ System Trauma Registry Expectations.It is important for trauma systemparticipants to define ongoing andfuture trauma information needs andto better define the expected role of thetrauma registry. Examples of futureneeds may include trend analysis, casemanagement, more precise epidemio-logical factors, expanded outcomeparameters (e.g., triage algorithm),and financial components of thetrauma system. There is also anongoing need to document the

system’s effectiveness. Should all orsome of these parameters and applica-tions be important to the traumasystem, then the trauma registryshould be so adjusted.

§ Future Integration. The County has thetrauma registry integration resourcesand has retained a company, DigitalInnovations, to update and integratethe QANet. This activity may representa timely opportunity for the traumasystem to completely reevaluatetrauma registry and integrate it intothe prehospital and EMS Agencyinformation system to ensure seam-less integration of their informationsystems with other EMS andhealthcare resources.


§ Off-line Medical Control. The AbarisGroup recommends reinforcing thecurrent effort to move to more off-linemedical control and data driven proto-cols. The Abaris Group acknowledgesthe current direction of that movementbut recommends accelerating the paceand deliverables perhaps through thedevelopment of a separate workgroupfor that purpose. This would allow thecounty to make a speedy transition toevidence-based protocols. Cautionshould be exercised to assure that thequality control system data is in placeto carefully measure the impact on thenew protocols. Once implemented,this would mean a substantive changein the role of the MICN and basehospital but their role would still beimportant for education and propersystem feedback.

§ Catchment Zones. MAC and the SanDiego County EMS Agency shouldrevisit the catchment zones as re-quested by the City of San Diego. Theirconcerns may be legitimate and theinitial analysis by The Abaris Group onvolume impact to the trauma centerssuggests a minimal impact fromchanging the zones.

§ Linkage with Trauma System. Improvedlinkages between prehospital care andthe trauma system are needed. Thereare gaps between the true integrationof the prehospital care component ofEMS in San Diego and the traumasystem. These gaps are largely input/feedback, educational, and traumapolicy involvement. As indicated underthe MAC recommendations andreinforced here, a global (throughTREF) or rotating prehospital grandround session should occur quarterlyhosted by the trauma centers. On theother triage and catchment zonerecommendations in this report, therecommendations assume substantialEMS input.

Prehospital

San Diego County’s prehospital careprogram as a component of the traumasystem represents a national best practiceEMS delivery system in terms of capabili-ties, coverage and performance. It isbecause of the prehospital care system(EMS providers, ground and air ambu-lance, and base hospitals) that an at-riskinjured trauma patient is consistentlytransported to a trauma center.

The following are The Abaris Group’srecommendations to enhance theprehospital care system’s role and integra-tion with the trauma system.

§ Prehospital Information System. Thecurrent process to re-engineer theprehospital care information systemshould be reinforced as a high systempriority to assure relevance, functionalityand timeliness. The current process ismanual, labor intensive, and redundant.The processes that are used to developinformation are slow and thus irrel-evant to the providers for daily man-agement needs. Data scanning at theCounty level is consistently 18 monthsbehind schedule with many contribut-ing factors. Some providers have beenforced to create redundant systems tomeet their information needs. Whilethere is a significant effort to re-engineer this system, it is not clearthat the information distributionsystem at the County level will improveas a function of that process.

§ Linked Injury Data. Data on injuredpatients should be linked from 9-1-1/PSAP dispatch to the field patient carereport, trauma registry and patientoutcome. This will make it possible toconduct geographic, care pathway andsystem outcome analyses on thetrauma system. Other system param-eters and sentinel events need to beclearly defined.


Trauma CenterConfiguration

The scope of this study required TheAbaris Group to provide an assessment oftrauma center configuration should therebe a trauma center reduction for anyreason. A baseline needs assessment onthe number or location of trauma centerswas not required within the scope of thisstudy, however, there was substantial inputprovided during this study on this topic.

§ Adding Trauma Centers. Addingtrauma centers in the current systemis not a viable option. Much was saidduring the interviews by prehospitaland hospital representatives outsidethe trauma centers about the need forincreased numbers and improvedlocations for the trauma centers in thecounty. For the prehospital staff, this ispurely about improving perceivedaccess. There was a clear bias by theseinterviewees encouraging more traumacenters in the north, south and eastparts of the county depending on thegeographic orientation of the inter-viewee. None of those who expressedan opinion about the need for moretrauma centers could rectify the neces-sary financial, volume and commit-ment issues that would surface withincreasing the number of traumacenters.

§ Reducing the Number of TraumaCenters. The current location of traumacenters are justified by volume, prox-imity to where injury occurs and theexisting trauma center depth of com-mitment and experience. There is alsoa need to establish sufficient numbersof trauma centers to assure depth ofcoverage for major incidents andpotential terrorist activities. A segmentof non-trauma center representativesinterviewed and to a lesser extentsome trauma center representativesexpressed opinions that there were too

“None of those who

expressed an opinion

about the need for

more trauma centers

could rectify the

recognized financial,

volume and commit-

ment issues that

would surface with

increasing the number

many trauma centers and those thatexisted were geographically misaligned(e.g. too many trauma centers in thecore of the county, insufficient num-bers in the outer areas). These inter-viewees also could not rectify theimportance of the institutional com-mitment, experience and clinicalexcellence of the existing traumacenters and the risk that reconfigura-tion might have on diluting theseimportant attributes. It is a fact thatmost of the trauma cases occur in ornear the downtown area of the county.Those interviewed admitted that theuse of ground and particularly air-medical services reduced their con-cerns but did not eliminate them dueto weather and other transport limita-tions.

§ Current Trauma Volumes. The traumacenters have the volume to supportoperations and clinical effectiveness.The Abaris Group evaluated volume(current and projected) at each traumacenter and for the system as a whole.While there are recommendations inthis report on evaluating triage criteria,the current volumes at each traumacenter meet or exceed The AbarisGroup’s minimum standard of 1,200trauma arrivals per year for clinical andfinancial efficacy. The Abaris Group hasalso predicted a modest growth intrauma center volume, thus enhancingthe existing volume. Even with theseprojections, The Abaris Group doesnot predict the need for another traumacenter in the near future.

§ Blend of Quality and Resource Avail-ability. The Abaris Group has con-cluded, based on the current operatingpolicies and assumptions of the SanDiego trauma system, that the existingtrauma center configuration (numberand location) represents the best blendof quality and available resourcesmatching the volume of cases. There-fore The Abaris Group does not recom-


mend changes to the trauma centerconfiguration.

§ Unexpected Reduction. The reductionof one trauma center would not col-lapse the resources of the traumanetwork but may strain these resourcesand have other unexpected impacts.The loss of two trauma centers wouldsignificantly tax the trauma network.The Abaris Group has provided somescenarios and analysis in this reportshould there be a reduction in thenumber of trauma centers. The AbarisGroup’s conclusion is that the loss ofone trauma center would tax prehospi-tal resources and the surviving traumacenters but there would be adjust-ments to system resources that couldresolve the impact without adding anadditional trauma center. Should twotrauma centers withdraw from thesystem, it is not likely that a replace-ment trauma center at the level ofcommitment and experience requiredwould be available. Therefore, thetrauma stakeholders would need tolook at reconfiguring the system forfour trauma centers. This wouldinclude evaluating the trauma triagestandards, developing a single indexcase (complex cases) trauma center(e.g. freestanding Level I with dedi-cated resuscitation, OR and intensivecare beds) such as has been done in afew metropolitan centers in the coun-try, developing a network of Level IIIcenters and/or a combination of theseefforts. These “what if” scenariosshould be further developed in astrategic planning process by theCounty EMS Agency in concert with thetrauma centers.


Leadership

As stated before, there is outstandingleadership at the trauma center level. TheCounty’s historical commitment to thetrauma centers and their leadership indeveloping trauma systems elsewhere inthe country should be recognized. TheCounty’s ongoing leadership with thetrauma system is clear with the authoriza-tion of this study and the many other EMSsystem design improvement effortsplanned or underway. The lack of contro-versial system issues is also an indicationof a well designed, collaborative andsupervised system. There is clearly adifferent and more positive collaborativetone of cooperation between the traumacenters and the County than in otherCalifornia trauma systems where therelationships tend to be characterized by a“buyer/seller” relationship.

All trauma system stakeholders expresseda desire to continue to mature the Countyand trauma center relationship into a truepartnership. There is also a need to con-tinue the strategic analysis work begun bythis study to assure a future sustainablequality trauma system. The barriers toaccomplishing this goal are access toresources at the County level, robustinformation systems, a mature partnershiprelationship between the County and thetrauma centers, and an empowered strate-gic leadership role at the County level.Changes to the leadership assumptionsand resources will be needed to accom-plish this.

The new environment recommended forthe system will take San Diego County’scredible trauma system to the next levelvia creating a shared vision and set ofexpectations. This will require clarity ofpurpose, empowerment and the resourcesto accomplish the mission. The traumacenters need to further develop theirshared view on “partnership” such that ithas few limitations to achieving the sharedvision. The County will need to identify

appropriate resources and allocate them toachieve this goal. This will be particularlychallenging but not impossible at theCounty level now that the County is experi-encing the pressures of the State budgetdeficit.

The Abaris Group’s leadership recommen-dations are as follows.

§ Defining Expectations. There is consid-erable variation between the providerexpectations of the County and theCounty of itself. There is a need tocollaboratively define strategic “leader-ship” expectations and deliverablesfrom the County. This can be accom-plished through the strategic planningprocess.

§ Linked Information System. There is aneed to develop a linked informationsystem that allows a complete assess-ment of trauma care from injury tooutcome. There should be clarity ofpurpose and integrity of the process.However, artificial limitations to usedata should be eliminated. This com-mitment cannot be understated and iscritical to continuing the ongoingconfidences of system and centerperformance and effectiveness.

§ Strategic Planning. Trauma systemstakeholders should collaborativelycreate a strategic vision of what the“partnership” role means between theCounty and all trauma stakeholders.This process should include envision-ing the future direction and prioritiesof the trauma system in general. Thisis likely to require a number of ses-sions and outside facilitation. Keypotential topic areas have been previ-ously mentioned in this report, but oneadditional target should includeconsideration of the excessive use oftrauma center resources through non-trauma center ED transfers.

“The new environ-

ment recommended

for the system will

take San Diego

County’s credible

trauma system to the

next level via creating

a shared vision and

set of expectations.”


§ Resources. As part of this process arealistic look at resources and empow-erment tools at the County level isneeded to allow the vision and deliver-ables to occur. The visioning processwill drive the resource needs whichshould include a realistic look atcurrent workload and priorities at theCounty level and access to additionalresources should the partnershiprequire this. This will take significantconsideration and priority setting bythe County, particularly in the face ofbudget constraints.

§ Epidemiologist and SurveillanceFunction. Even prior to the conclusionof the strategic planning process thereis a need by the County to begin toreaffirm priorities and resource alloca-tion for the County’s epidemiology andsurveillance team. The blend betweenmeeting priority needs, resources anddeveloping a friendly but cost-effectiveinformation management and report-ing system is important to this consid-eration. There are clear targets recom-mended in this report (e.g. triagestudy, trending, and report publication)that should be taken into account andmelded with the other EMS system andinjury prevention needs with the short-and medium-term plans of these staff.

§ Implementing Initiatives. In partner-ship, the County and trauma stakehold-ers should continue to implement andrefine strategic initiatives based on thedeveloped strategic vision/plan. Thisshould be done with the developmentof an action plan, time defined deliver-ables and performance measures.


Fiscal Planning

The cost of trauma care and the technol-ogy needed to meet the complex needs ofthe trauma patient continue to rise.Current revenue sources for trauma pa-tients are fragile and constantly at risk.Creating a stable and sustainable fundingsource for the trauma system is a criticalneed. This funding is needed at the traumacenter and system leadership levels (EMSAgency).

The Abaris Group’s study of operations ateach trauma center concluded that thetrauma centers are at best practice as itrelates to trauma center cost controls, andwhile more could be done to optimizecosts (e.g. system-wide clinical pathways),such efforts would likely only achievenominal effects. The Abaris Group alsoidentified that there are better and bestpractices in place at the trauma centers onrevenue cycle management. The cost andrevenue facts are largely the reason thatSan Diego County’s trauma system hasbeen as stable as it has been for the past18 years. Recent subsidization of thetrauma centers through State and localfunds has also helped, but this funding hasbeen nominal and much of those funds areonetime sources.

There are very limited areas in the countrywhere publicly supported dollars are usedfor trauma centers. Those that do exist(e.g. Alameda, Los Angeles and PalmBeach (FL) Counties) are exceptions, andtheir success is largely a product of devel-oping a clear need and formal efforts toachieve public support for funding theseneeds. Such efforts have not been fullytested in San Diego.

§ Optimizing Current Resources. One ofthe challenges for trauma centers indeveloping a public-funded effort is toassure that all current revenue oppor-tunities are optimized. All traumacenters indicated that they had oppor-

“Creating a stable

and sustainable

funding source for the

trauma system is a

critical need. This

funding is needed at

the trauma center

and system leadership

levels (EMS

Agency).”

tunities to improve revenue for traumacare and several indicated and wereobserved to have potential for signifi-cant improvement. These traumacenters should undertake high-priorityefforts to achieve those potentials.

§ County Funding. There do not appearto be any resources at the County levelfor direct trauma center fundingbeyond those that are in place today(e.g. SB 12/612 funding). Even so, suchCounty funding would likely come withsignificant audit and review responsi-bilities for the trauma centers, andfrom a resource and cost standpoint,may obviate the modest County fund-ing that might be available. The Countyhas indicated a commitment to assistthe trauma centers in locating stablesources of funding for the traumacenters and system leadership at theCounty level.

§ Statement of Need. Consistent withprevious observations in this report, aclearer statement of need for publicsupport should be developed by thetrauma system to provide a stable andsustainable source of funding for thefuture. The funding would be used toassist the trauma centers and EMSAgency. This effort should be followedby a careful analysis of public supportfor developing a stable source offunding for the system, perhapsthrough a tax initiative, and thenpursuing that initiative.

§ Pursue Stable Funding Sources. Pursu-ing stable funding sources for thetrauma system should be a highpriority as future changes to thesystem appear to assure a wideninggap between cost and revenue. Theplanning for a stable funding sourcemight be included in the MAC strate-gic initiatives mentioned previously.


VI. Appendices


Appendix A: Study Participants

Category Name Title Affiliation

Ambulance Dallas Johnson Operations Supervisor AMR

Ambulance Theresa Matlock EMT-P AMR

Ambulance Anna Rangel EMT-P AMR

Ambulance Kelly Forman, RN Business Development Coordinator Mercy Air

Ambulance Pam Steen, RN Former Trauma QA Specialist Mercy Air

Ambulance Wayne Johnson Director of Operations San Diego Medical Services Enterprise

Ambulance Devin Price Member of Emergency Medical Care Committee San Diego County Paramedic Association

Ambulance Ann Loring, RN Nurse Coordinator Schafer Ambulance Services

Ambulance David Harker EMT-P Sycuan Ambulance

County Susan Barnes, RN Public Health Nurse III Adult Protective Services

County Carmen Duron, RN Public Health Nurse III Adult Protective Services/AIS

County Brian Blackbourne, MD Medical Examiner County of San Diego

County Walter F Ekard Chief Administrative Officer County of San Diego

County Nick Macchione N Coastal/N Inland Region General Manager County of San Diego

County Betty Morell South Region General Manager County of San Diego

County Patti Rahiser N Central Region General Manager (acting) County of San Diego

County Rene Santiago Central Region General Manager County of San Diego

County Jack Walsh, RN Public Health Nurse County of San Diego

County Bonnie Copland, RN Public Health Nurse III East Region Public Health Center

County Tamara Bannan HPPS Health & Human Services

County Diane Hall, RN Nurse Manager Health & Human Services

County Amy Hoover Engineer Technician Health & Human Services

County Jackie Werth Planning Specialist Health & Human Services

County Martha Bartzen Public Health Nurse Manager Health & Human Services/East Region

County Rhonna Bunelle Assistant Deputy Director Health & Human Services/East Region

County Elizabeth Villafranco Student Intern Health & Human Services/East Region

County Carol Judkins, RN Public Health Nurse Manager Health & Human Services/North Central Region

County E Lorentz Health Promotions Health & Human Services/North Region

County Karen Mason Mental Health Consultant Health & Human Services/North Region

County Carey Riccitelli Health Specialist Health & Human Services/North Region

County Blair Hoppe Legislative Analyst Health & Human Services/South Region

County Oscar Talaro Community Liaison Health & Human Services/South Region

County Pilar Velasco Protective Services Health & Human Services/South Region

County Gwenmarie Hillary Assitant Deputy Director Public Health Services

County Gail F Cooper Public Health Administrator San Diego County Office of Public Health

County Les Gardina, RN Trauma QA Specialist San Diego County EMS Agency

County Gwen Jones Chief of EMS San Diego County EMS Agency

County Nevea Ledesma Trauma Program Assistant San Diego County EMS Agency

County Marcy Metz, RN QA Specialist San Diego County EMS Agency

County Patti Murrin, RN, MPH EMS Coordinator - Trauma San Diego County EMS Agency

County Sharon Pacyna, RN, BSN, MPH QA Specialist/CIREN Manager San Diego County EMS Agency

County Leslie Upledger Ray, MA, MPPA Senior Epidemiologist San Diego County EMS Agency

County Patty Danon Deputy Chief of Staff Supervisor Greg Cox's Office

County Anthony Orlando Senior Policy Advisor Supervisor Ron Roberts' Office

San Diego CountyTrauma System Assessment Study Participants


Appendix A: Study Participants, cont.


Fire Dick Gardner Fire Captain California Department of Forestry/Deer Springs

Fire Shane Vargas Firefighter II California Department of Forestry/Deer Springs

Fire Brian Watson Division Chief Carlsbad Fire Department

Fire Tom Layman Battalion Chief Chula Vista Fire Department

Fire Alan Nowakowski Division Chief - EMS Coronado Fire Department

Fire Rodney Geilenfeldt Paramedic El Cajon Fire Department

Fire Debra Murphy, RN, MICN EMS Coordinator Escondido Fire Department

Fire Victor Reed Fire Chief Escondido Fire Department

Fire Kevin Dubler Fire Chief Julian Fire Department

Fire Andrew Parr EMS Coordinator Lakeside Fire Department

Fire Jim Myers EMS Chief Oceanside Fire Department

Fire Charles T Gahn Chief Ocotillo Wells Fire Department

Fire Don Butz Deputy Chief Rancho Santa Fe Fire Protection District

Fire Bruce Cartelli Battalion Chief San Diego Fire Department

Fire Letto Contreras Communications Center Manager San Diego Fire Department

Fire Roger Fisher QA Manager San Diego Fire Department

Fire Patricia Nunez Human Resources Manager San Diego Fire Department

Fire Ginger Ochs, RN QI Manager San Diego Fire Department

Fire Mike Pacheco Operations Coordinator San Diego Fire Department

Fire Perry Peak Battalion Chief San Diego Fire Department

Fire Dave Power Firefighter, EMT-P San Diego Fire Department

Fire Mark Sundberg Firefighter, EMT-P San Diego Fire Department

Fire Rolf Trautwein Captain San Diego Fire Department

Fire Jeff Tyranski Firefighter, EMT-P San Diego Fire Department

Fire Andy Uzdiavines Captain San Diego Fire Department

Fire Bret Eldridge Captain/Former Paramedic Santee Fire Department

Fire Robert Ironside Engineer Santee Fire Department

Fire Bob Pfohl Fire Chief Santee Fire Department

Fire George K George Fire Chief Solana Beach Fire Department

Fire Marilyn Anderson, RN EMS Coordinator Vista Fire Protection District

Fire Tammy McGill EMT Warner Springs Volunteer Fire Department

Hospital Paul Hartup Interim ED Manager Alvarado Hospital

Hospital Louis Coffman Chief Financial Officer Children's Hospital & Health Center

Hospital David DeBeck Decision Support Analyst Children's Hospital & Health Center

Hospital Susan Duthie, MD Assistant Director of Critical Care Children's Hospital & Health Center

Hospital Jim Harley, MD Emergency Medicine Children's Hospital & Health Center

Hospital Buzz Kaufman, MD Senior Vice President, Health Affairs Children's Hospital & Health Center

Hospital Donald Kearns, MD Medical Director of Surgical Services Children's Hospital & Health Center

Hospital Cindy Kuelbs, MD Medical Director Chadwick Center Children's Hospital & Health Center

Hospital Michael Levy, MD Director of Pediatric Neurosurgery Children's Hospital & Health Center

Hospital Bradley Peterson, MD Medical Director, Critical Care Children's Hospital & Health Center

Hospital Blair Sadler Chief Executive Officer Children's Hospital & Health Center

Hospital Kathy Webb Contracts Children's Hospital & Health Center

Hospital Jim Dunford, MD Medical Director City of San Diego/UCSD

Hospital William Linnik, MD Base Hospital Medical Director Grossmont Hospital

Hospital Mary Meadows-Pitt, RN Base Hospital Nurse Coordinator Grossmont Hospital

Hospital Sharon Andrews, RN, MSN Director of Adult Impatient Services Palomar Medical Center





Hospital Barbara Bateman, RN, MBA Director of Perioperative Services Palomar Medical Center

Hospital Shelley Berthiaume, RN Base Hospital Nurse Coordinator Palomar Medical Center

Hospital Gerald Bracht Chief Executive Officer Palomar Medical Center

Hospital LeAnne Cooney Financial Planning/Decision Support Palomar Medical Center

Hospital Taylor Fletcher, MD Emergency Medicine Palomar Medical Center

Hospital Michelle Grad, MD Base Hospital Medical Director Palomar Medical Center

Hospital Bob Hemker Chief Financial Officer Palomar Medical Center

Hospital Pam Hoppie, RN ED Nurse Manager Palomar Medical Center

Hospital Lourdes Januszewicks, RN, BSN, CCRN Nurse Manager Critical Care Unit Palomar Medical Center

Hospital Catherine Konyn, RN, MSN Nurse Manager/CNS Critical Care Unit Palomar Medical Center

Hospital Kevin Metros, MD Orthopedic Surgeon Palomar Medical Center

Hospital Gabriella Morris, MD Neurosurgeon Palomar Medical Center

Hospital Raluan Soltero, MD Plastic Surgeon Palomar Medical Center

Hospital Kathleen Stacy, RN, MSN, CCRN Nurse Manager Intermediate Care Unit Palomar Medical Center

Hospital Arlene Cawthorne Community Research Specialist Palomar/Pomerado Behavioral Health

Hospital Kevin Anderson Finance Scripps Healthcare

Hospital Lisa Otte Cost Accounting Manager Scripps Healthcare

Hospital Kay Young Fiscal Director Scripps Healthcare

Hospital Linda Broyles, RN Base Hospital Nurse Coordinator Scripps Memorial Hospital - Chula Vista

Hospital Mary Margeret Leohr, MD Base Hospital Medical Director Scripps Memorial Hospital - Chula Vista

Hospital Mel Ochs, MD Former EMS Medical Director Scripps Memorial Hospital - Chula Vista

Hospital John Armstrong Finance Scripps Memorial Hospital - La Jolla

Hospital Andrew Cliff Senior Financial Analyst Scripps Memorial Hospital - La Jolla

Hospital Sean Evans, MD Base Hospital Medical Director Scripps Memorial Hospital - La Jolla

Hospital Gary Fybel Chief Executive Officer Scripps Memorial Hospital - La Jolla

Hospital David Hackley, MD Orthopedic Surgeon Scripps Memorial Hospital - La Jolla

Hospital Mary Johnson, RN Base Hospital Nurse Coordinator Scripps Memorial Hospital - La Jolla

Hospital Cindy Steckel, RN Trauma Administrator Scripps Memorial Hospital - La Jolla

Hospital Lisa Thackur Director of Fiscal Services Scripps Memorial Hospital - La Jolla

Hospital Lance Alteneau, MD Neurosurgeon Scripps Mercy Hospital & Medical Center

Hospital Melissa Burns, RN ICU Nurse Manager Scripps Mercy Hospital & Medical Center

Hospital Davis L Cracroft, MD Chief of Staff Scripps Mercy Hospital & Medical Center

Hospital Kent Dively, MD Anesthesiologist Scripps Mercy Hospital & Medical Center

Hospital Tom Gammiere Chief Executive Officer Scripps Mercy Hospital & Medical Center

Hospital Leanne Hunstock, RN Chief Nurse Executive Scripps Mercy Hospital & Medical Center

Hospital Barbara Loma, RN Nurse Practitioner Scripps Mercy Hospital & Medical Center

Hospital Sheri Mankin ED Manager Scripps Mercy Hospital & Medical Center

Hospital Kim McEvoy Director, Surgical Services Scripps Mercy Hospital & Medical Center

Hospital Linda Rod, RN Nurse Practitioner Scripps Mercy Hospital & Medical Center

Hospital Jackie Saucier ED Manager Scripps Mercy Hospital & Medical Center

Hospital David J Shaw, MD MD Specialist Scripps Mercy Hospital & Medical Center

Hospital Charles W Simmons, MD ED Medical Director Scripps Mercy Hospital & Medical Center

Hospital William Tontz, MD Orthopedic Surgeon Scripps Mercy Hospital & Medical Center

Hospital Michael Lenihan, MD Orthopedic Surgeon Sharp Chula Vista Medical Center

Hospital Dan Gross Chief Executive Officer Sharp Memorial Hospital

Hospital Mark Kramer, MD Base Hospital Medical Director Sharp Memorial Hospital

Hospital Sharon Rudnick, RN Nurse Coordinator Sharp Memorial Hospital

Hospital Susan Smith, RN Base Hospital Nurse Coordinator Sharp Memorial Hospital

Hospital Kevin Thompson Chief Financial Officer Sharp Memorial Hospital





Hospital Beth N Liguon Director Tri-City Medical Center

Hospital Dori Vroman, RN Base Hospital Nurse Coordinator Tri-City Medical Center

Hospital Todd Zaayer, MD Base Hospital Medical Director Tri-City Medical Center

Hospital Lana Brown, RN Base Hospital Nurse Coordinator UCSD (AMR) Base

County Gary Vilke, MD EMS Medical Director San Diego County EMS Agency

Hospital Karilyn Greenwood Director of Decision Support UCSD Medical Center

Hospital David Guss, MD Emergency Department UCSD Medical Center

Hospital Robert Hogan CFO/Director of Financial Administration UCSD Medical Center

Hospital Sumiyo Kastelic Administrator UCSD Medical Center

Hospital Kathy Bay, CNS Emergency Department United States Naval Hospital

Hospital David Tam, MD Director of Branch Medical Clinics United States Naval Hospital

Non-Trauma Pat Coakley Director Kaiser Foundation Hospital

Non-Trauma Stephanie Baker, RN, CEN, BSN Director of Emergency Services Paradise Valley Hospital

Non-Trauma Trish McAvliffe, RN Nurse Villa View Community Hospital

Organizations Linda Peek Associate Director Altam Associates

Organizations Grover Diemert Executive Director Bayside Community Center

Organizations Lisa Cardenas Program Coordinator CA Perinatal Transport System

Organizations Catureena San Juan King Program Coordinator CA Perinatal Transport System

Organizations Nicki Clay Partner Clay & Associates

Organizations Stephanie Saathoff Associate Clay & Associates

Organizations Heather Summers Violence Prevention Specialist El Cajon Collaborative ECVR

Organizations Kevin Hutton, MD CEO/President Golden Hour Data Systems

Organizations Bradford Burnett, MD, MBA Member Health Services Advisory Board

Organizations Steven A Escoboza CEO/President Healthcare Assoc of San Diego & Imperial Counties

Organizations Sonja Fulton Director of Program Development Healthcare Assoc of San Diego & Imperial Counties

Organizations Liz Kruidenier Social Policy Chair League of Women Voters - North Coast

Organizations Katherine Smith-Blanke Chair Mental Health Board

Organizations Cindy Lechien Director of Operations Mountain Health & Community Services

Organizations Trina Souza, RN RN Clinical Coordinator Mountain Health & Community Services

Organizations Bob Borden Coordinator/Teacher National Alliance for Mental Illness

Organizations Bob Brooks Coordinator National Alliance for Mental Illness

Organizations Roxanne Hoffman Coordinator Safe Kids Coalition

Organizations Mike Casinelli Executive Director Trauma Research Education Foundation

Organizations Myrtle Cassell Director Warner Community Resource Center

Other Dean Stowers Police Officer California Highway Patrol

Other Nicky Fontitus, MD Physician North County Collaborative

Other Brad Wiscons E.D. North County Collaborative

Other Debi Moffat Director of EMS Palomar College

Other John Seiferth Deputy San Diego County Sheriff

Other Jo Chappel, RN EdD Sweetwater Union High School District

Other Francis Deogracias US INS US INS

Other Steven Whiteley US INS US INS

Trauma Sue Cox, RN, MS, CEN Trauma Nurse Manager Children's Hospital & Health Center

Trauma Renee Douglas, RN Trauma Clinical Coordinator Children's Hospital & Health Center

Trauma Barry LoSasso, MD, FACS, FAAP Trauma Medical Director Children's Hospital & Health Center

Trauma Laura Maresh Trauma Registrar Children's Hospital & Health Center

Trauma Berda Taylor Trauma Business Unit Coordinator Children's Hospital & Health Center

Trauma C Douglas Wallace, MD Director of Orthopedic Trauma Children's Hospital & Health Center




Category N a m e Tit le Af f i l ia t ion

Trauma Lawrence Marshall, MD Director of Neurosurgical Trauma Children's Hospital & Health Center/UCSD

Trauma Kim Colonelli, RN, MA Trauma Nurse Manager Palomar Medical Center

Trauma Shannon Durbin-Yates, RN, BSN Trauma Clinician Palomar Medical Center

Trauma Maureen Goehring, RN Former Trauma Nurse Manager Palomar Medical Center

Trauma Patricia Renaldo, RN, BSN Trauma Clinician Palomar Medical Center

Trauma Sally Valle Department Secretary Palomar Medical Center

Trauma Thomas Velky, MD Trauma Medical Director Palomar Medical Center

Trauma A Brent Eastman, MD, FACS Trauma Medical Director Scripps Memorial Hospital - La Jolla

Trauma Jackie Martinez, RN, BSN, CCRN Trauma Case Manager Scripps Memorial Hospital - La Jolla

Trauma Brian McCord ICU Manager Scripps Memorial Hospital - La Jolla

Trauma Monte Mellon, MD Chair ED Scripps Memorial Hospital - La Jolla

Trauma Richard Ostrup, MD Neurosurgeon Scripps Memorial Hospital - La Jolla

Trauma Marc M Sedwitz, MD Trauma Surgeon Scripps Memorial Hospital - La Jolla

Trauma Fred Smith, Jr, MD Director of Trauma Scripps Memorial Hospital - La Jolla

Trauma Steve Wickham, RN, MN Director of Emergency Department and Trauma Scripps Memorial Hospital - La Jolla

Trauma Jennifer Wilson, RN, BSN, ONC Trauma Case Manager Scripps Memorial Hospital - La Jolla

Trauma Cheryl Wooten, MSN, RN, CNRN Trauma Nurse Manager Scripps Memorial Hospital - La Jolla

Trauma Michael Egan, MD Trauma Surgeon Scripps Mercy Hospital & Medical Center

Trauma Dot Kelley, RN, MSN, CEN Trauma Nurse Manager Scripps Mercy Hospital & Medical Center

Trauma Bonnie Lutz Trauma Registry Scripps Mercy Hospital & Medical Center

Trauma Michael Sise, MD, FACS Trauma Medical Director Scripps Mercy Hospital & Medical Center

Trauma Beth Sise, JD, RN, MSN, CPNP Director, Injury Prevention and Outreach Scripps Mercy Hospital & Medical Center

Trauma Jack C Yang, MD Trauma Surgeon Scripps Mercy Hospital & Medical Center

Trauma Kathi Ayers, RN, MSN, MSNP Trauma Nurse Manager Sharp Memorial Hospital

Trauma Frank Kennedy, MD, FACS Trauma Medical Director Sharp Memorial Hospital

Trauma Janie Taylor, RN Trauma Administrator Sharp Memorial Hospital

Trauma Dale Fortlage Trauma Registrar UCSD Medical Center

Trauma Jennifer Hall Trauma Case Manager UCSD Medical Center

Trauma Peggy Hollingsworth-Fridlund, RN, BSN Trauma Nurse Manager UCSD Medical Center

Trauma David Hoyt, MD, FACS Trauma Medical Director UCSD Medical Center

Trauma Alexandra Schwartz, MD Chief of Trauma/Orthopedics Division UCSD Medical Center

Trauma Patricia Stout, RN Trauma Registrar UCSD Medical Center

Trauma Jeff Smith, MD Orthopedic Surgeon UCSD Medical Center/CIREN

San Diego CountyTrauma System Assessment Study Part ic ipants


The following expert team members and Abarisstaff were consulted with and contributed to thisstudy:

Principal investigators:

Pennie Klein, RN, MALead Trauma System Nurse Expert

Ms. Klein has been working in trauma andtrauma systems since the 1980’s and hasextensive experience in trauma system andtrauma center level management. She is therecent past Trauma System Coordinator for theState of Arizona, where she had overall responsi-bility for the development and monitoring of thestate trauma program.

Kimball Maull, MDLead Physician Consultant

Dr. Maull is Director of the Carraway TraumaCenter, Attending Surgeon and Director of theSurgery Residency Program at Carraway Method-ist Medical Center in Birmingham, Alabama. Heis also a Senior Scientist at the University ofAlabama at Birmingham’s Injury Control Re-search Center. Dr. Maull is the recent pastMedical Co-Director for the National HighwayTraffic Safety Administration (NHSTA) and theU.S. Department of Transportation (DOT)National EMT-B Standard Curriculum (1990-94).He has had many academic and professionalappointments related to trauma and numerousarticles (158) and presentations (325) to hiscredit regarding EMS/trauma systems.

Mike Williams, MPA/HSAProject Director

Mike has been the president of The Abaris Groupfor the past 13 years and has been a full-time EMSconsultant for the past 22 years. Before consult-ing, he was Director of the Office of EmergencyMedical Services for Orange and Imperial Coun-ties, California. Mike is a long-standing member ofthe American Trauma Society and is a nationallyrecognized speaker on the subject of accountabil-ity and performance in the emergency-care field.

Other professional andconsultative staff:

Chuck BaucomDatabase & GIS/Mapping Expert

Mr. Baucom has assisted The Abaris Group withdata management and mapping resources withnumerous EMS consulting projects in Idaho,Colorado and California. Mr. Baucom is the EMSAdministrator for the County of Merced and hasbeen involved in emergency medical servicessince 1973.

Denis David Bensard, MDPediatric Trauma SurgeonConsultant

Dr. Bensard is Associate Professor of Surgery inthe Pediatric Surgery Division at University ofColorado (CU) School of Medicine. He has heldnumerous academic appointments including:Assistant Professor of Surgery and Pediatricsand Pediatric Surgery at CU, Director of SurgicalIntensive Care Unit at Veteran’s AdministrationHospital, Director of Trauma at Children’sHospital Regional Trauma Center, CouncilMember Adam’s County Trauma AdvisoryCouncil, and Surgical Co-Director of ICU atChildren’s.

Pam Goslar, Ph.D., CPAInjury Epidemiologist Expert

Dr. Goslar has worked in the field of injuryepidemiology for approximately ten years. Forthe past two years she has been at St. Joseph’sHospital and Medical Center, an ACS verifiedLevel I Trauma Center in Phoenix, Arizona, whereshe is responsible for building the TraumaPrevention and Outcomes Research Program.She has served on a variety of state and localtrauma committees.

Appendix B: The Abaris Group Team


Heidi Hotz, RNTrauma System Nurse Expert

Ms. Hotz’s experience in trauma care, traumasystems, and trauma program management span20 years. She is currently the Trauma ProgramManager at Cedars-Sinai Medical Center in LosAngeles and maintains membership on the LACounty Trauma Hospital Advisory Committee.She is also the President of the Society of TraumaNurses.

Jonathan Jui, MD, MPHEMS/EDMD Physician Consultant

Dr. Jui is a Professor in Emergency Medicine atOregon Health Sciences and University(OHSU), Portland, Oregon and a nationallyrecognized EMS system medical director. He isboard certified in Emergency Medicine, Infec-tious Disease, and Intern=al Medicine. He serveson many committees in Oregon. He also holdsa Masters in Public Health in Epidemiologyfrom the University of Washington.

Peter Letarte, MDTrauma Neurosurgeon Consultant

Dr. Letarte is an Assistant Professor of Neuro-logical Surgery at Loyola University MedicalCenter, Illinois with a specific interest inNeurotrauma, Critical Care, Spinal Surgery,Peripheral Nerve and General Neurosurgery.He served eight years in the military as a U.S.Naval Flight Surgeon in Japan, Florida, andPennsylvania. Dr. Letarte is board certified bythe National Board of Medical Examiners and isa diplomat of the American Board of Neurologi-cal Surgery.

Ernest Moore, MD, FACS, FCCM,FACNTrauma Physician Consultant

Dr. Moore has been the Chief of TraumaServices at the Rocky Mountain RegionalTrauma Center, Denver Health Medical Centersince 1976. He is also the Chief of the Depart-ment of Surgery at Denver Health MedicalCenter, Professor of Surgery and the Vice Chairof the Surgery Department at the University ofColorado Health Sciences Center. Dr. Moore isalso extensively published. He is co-author of

“Trauma,” now in its 5th edition, and a contributingauthor to the American College of SurgeonsCommittee on Trauma’s “Resources for OptimalCare of the Injured Patient” (1993 and 1999editions).

Bev Ness, RN, BSNTrauma System Nurse Expert

Ms. Ness has worked with The Abaris Group fornearly seven years as a strategic planning andproject coordination expert on a variety of traumaprojects. Her past experience includes traumasystem manager for the Nor-Cal EMS, Inc. regionfor eight years, and she was the Trauma NurseCoordinator for the State of Arizona for three years.She has also written trauma plans for NorthernCalifornia EMS, Inc., Riverside County and for theFresno, Kings, Madera EMS region.

Wade Smith, MDTrauma Orthopedic SurgeonConsultant

Dr. Smith is the Director of the Department ofOrthopedic Surgery at the Rocky MountainRegional Trauma Center at Denver HealthMedical Center. He is also the Director of theAlpha Omega Trauma Fellowship at DenverHealth Medical Center. His is presently ap-pointed as the Assistant Professor of OrthopedicSurgery at the University of Colorado HealthSciences Center. Dr. Smith has also served as theCo-Director of Orthopedic Trauma at DenverHealth Medical Center for the past four years.

Taylor BluskeExecutive Assistant

Taylor is Executive Assistant at The AbarisGroup. Along with maintaining companyaccounts and bookkeeping, Taylor providesprogram coordination, client report preparation,and report graphics and design. Her previousexperience includes working as a dispatcher forthe Contra Costa County Sheriff’s Office.

Juliana C. Boyle, MBAEconomist

Juliana is a full-time economist for The AbarisGroup and has worked with the firm for almost 8years. She has many years of experience analyz-ing a wide range of health related data. Her


experience includes seven years as an economistwith the University of New Mexico, Bureau ofBusiness and Economic Research and five years asa policy analyst/economist for the State of NewMexico, where she was involved in analyzingvarious health care reform proposals and theirpotential impact on the state.

Carla GomezResearch Assistant

Carla is a Research Assistant at The AbarisGroup. Carla graduated from University ofCalifornia, Berkeley with a Bachelor of Arts inRhetoric. She provides research support forprojects, assists with data and client reportpreparation, and spreadsheet calculations.

Jonathan WillsResearch Assistant

Jonathan is a Research Assistant at The AbarisGroup. Jonathan has a Bachelor of Arts inEconomics from the University of California,Berkeley. He has worked on a number of projectsincluding the research and publication of bestpractice policies on emergency departmentdiversion and the development of research toolsto assess compensation issues for traumasurgeons.


Abbreviated Injury Scale (AIS) - is an anatomicseverity scoring system. For the purposes of datasharing, the standard to be followed is AIS 90. For thepurpose of volume performance measurementauditing, the standard to be followed is AIS 90, usingAIS code derived or computer derived scoring.

Advanced life support (ALS) - medically accepted, lifesustaining, invasive procedures, provided at thedirection of a physician or authorized registerednurse.

Ambulance service - a qualified provider of medicaltransportation for patients requiring treatment and/ormonitoring due to illness or injury.

Base hospital - one of a limited number of hospitalswhich, upon entering into written contractualagreement with the local EMS agency, is responsiblefor directing the advanced life support system orlimited advanced life support system assigned to it.

Basic life support (BLS) - medically accepted non-invasive procedures used to sustain life.

Catchment area - the geographic area served by aspecified health care facility, trauma center or EMSagency.

Centralized EMS dispatch center - a system which isresponsible for establishing communicationschannels and identifying the necessary equipment andfacilities to permit immediate management andcontrol of an EMS patient. This operation mustprovide access and availability to public safetyresources essential to the effective and efficient EMSmanagement of the immediate EMS problem.

Communications system - those resources andarrangements for notifying the EMS system of anemergency, for mobilizing and dispatching resources,for exchanging information, for remote monitoring ofvital indicators, and for the radio transmission oftreatment procedures and directions.

Definitive care - a level of therapeutic interventioncapable of providing comprehensive health careservices for a specific condition.

Designated facility - a hospital which has beendesignated by a local EMS agency to performspecified emergency medical services systemsfunctions pursuant to guidelines established by theauthority.

Emergency ambulance service - an emergencymedical transport provider operating within anorganized EMS system for the purpose of assuringtwenty-four (24) hour availability of such services.

This pertains to all ground, air or water emergencymedical transport.

Emergency department - the area of a licensedgeneral acute care facility that customarily receivespatients in need of emergent medical evaluation and/or care.

Emergency medical services (EMS) - the provision ofservices to patients requiring immediate assistancedue to illness or injury, including access, response,rescue, prehospital and hospital treatment, andtransportation.

EMS plan - a plan for the delivery of emergencymedical services.

EMS system - a coordinated arrangement ofresources (including personnel, equipment, andfacilities) which are organized to respond to medicalemergencies, regardless of the cause.

First responder - the first person (unit) dispatched tothe scene of a medical emergency to provide patientcare.

Health facility - any facility, place or building which isorganized, maintained and operated for the diagnosis,care and treatment of human illness or injury, physicalor mental, including convalescence, rehabilitationand/or pre- and post-natal care, for one or morepersons, to which patients are admitted for twenty-four (24) hours or longer.

Hospital - an acute care hospital licensed underChapter 2 (commencing with Section 1250) ofDivision 2, Health and Safety Code.

Immediately or immediately avai lable -means unencumbered by conflicting duties orresponsibilities; responding without delay whennotified; and being physically available to the specifiedarea of the trauma center when the patient isdelivered in accordance with local EMS agencypolicies and procedures.

Inclusive trauma care system - means asystem that is designed to meet the needs of allinjured patients. The system shall be defined by thelocal EMS agency in its trauma care system plan.

Injury Severity Score (ISS) - means the sum ofthe squares of the Abbreviated Injury Scale score ofthe three most severely injured body regions.Intervener physician - a physician on the scene of amedical emergency who offers to assist advanced lifesupport personnel.

Medical control - physician responsibility for thedevelopment, implementation, and evaluation of theclinical aspects of an EMS system.

Appendix C: Definitions


Medical protocol - pre-established physicianauthorized procedures or guidelines for medical careof a specified clinical situation, based on patientpresentation.

On-call - means agreeing to be available torespond to the trauma center in order to provide adefined service.

Over Triage - Over-triage is generally defined asthose patients that did not need the services of atrauma center, usually translated as those patientstriaged to a trauma center but sent home from theED. Under-triage includes high risk patients that aretransported to a non-trauma center or that gounrecognized as a high risk patient at a traumacenter.

Prehospital emergency medical services - asub-system of the emergency medical servicessystem which provides medical services to patientsrequiring immediate assistance due to illness orinjury, prior to the patient’s arrival at an emergencymedical facility.

Prehospital time - the interval of time betweenactivation of the emergency medical transportresponse to an emergency incident and arrival of theemergency patient at a receiving facility.

Promptly or promptly available - means respondingwithout delay when notified and requested to respondto the hospital; and being physically available to thespecified area of the trauma center within a period oftime that is medically prudent and in accordance withlocal EMS agency policies and procedures.

Provider - an organization, institution, or individualauthorized to provide direct patient care.

Public safety agency - a functional division of a publicagency which provides fire fighting, police, medical orother emergency services.

Public safety answering point (PSAP) - thelocation at which an emergency telephone call isanswered and, either appropriate resources aredispatched or the request is relayed to the respondingagency.

QANet - this is a real time, computerzed wide arenetwork (WAN) thta is used to collect and storepatient information and hospital resource availabilityand to link all emergency receiving hospitals,including trauma centers, base hospitals and SARTfacilities; ALA ambulances, including air medicalproviders; BLS ambulance providers; emergency

medical dispatch agenices and he Medical Examinersoffice.

Qualif ied specialist/qualif ied surgicalspecialist/qualif ied non-surgical specialist -means a physician licensed in California who is boardcertified in a specialty by the American Board ofMedical Specialties, the Advisory Board forOsteopathic Specialties, a Canadian board or otherappropriate foreign specialty board as determined bythe American Board of Medical Specialties for thatspecialty.

(a) A non-board certified physician may berecognized as a “qualified specialist” by the local EMSagency upon substantiation of need by a traumacenter if:(1) the physician can demonstrate to the appropriatehospital body and the hospital is able to documentthat he/she has met requirements which areequivalent to those of the Accreditation Council forGraduate Medical Education (ACGME) or the RoyalCollege of Physicians and Surgeons of Canada;(2) the physician can clearly demonstrate to theappropriate hospital body that he/she has substantialeducation, training, and experience in treating andmanaging trauma patients which shall be tracked bythe trauma quality improvement program; and (3)the physician has successfully completed a residencyprogram.

Quality assurance/quality improvement - a method ofevaluation of services provided, which includesdefined standards, evaluation methodology(ies), andutilization of evaluation results for continued systemimprovement.

Receiving hospital - means a licensed general acutecare hospital with a special permit for basic orcomprehensive emergency service, which has notbeen designated as a trauma center according to thisChapter, but which has been formally assigned a rolein the trauma care system by the local EMS agency. Inrural areas, the local EMS agency may approvestandby emergency service if basic or comprehensiveservices are not available.

Residency program - means a residency program ofthe trauma center or a residency program formallyaffiliated with a trauma center where senior residentscan participate in educational rotations, which hasbeen approved by the appropriate Residency ReviewCommittee of the Accreditation Council on GraduateMedical Education.

Response time - the total interval from receipt of arequest for medical assistance to the primary publicsafety answering point (PSAP) to arrival of theresponding unit at the scene. This includes alldispatch intervals and driving time.

Appendix C: Definitions, cont.


SDEMSA - refers to the County of San Diego, Healthand Human Services Agency, Diversion of EmergencyMedical Services.

Secondary care - health care beyond the primary.Included are more sophisticated diagnostic methodsand techniques, and laboratory facilities. This level ofcare is nearly available in medical care institutionsserving a large population. (SOURCE: Tabors, 16thedition). Contrast with primary and tertiary care.

Senior resident or senior level resident -means a physician, licensed in the State of California,who has completed at least three (3) years of theresidency or is in their last year of residency trainingand has the capability of initiating treatment andwho is in training as a member of the residencyprogram as defined in Section 100244 of this Chapter,at the designated trauma center.

Service area - means that geographic area definedby the local EMS agency in its trauma care systemplan as the area served by a designated traumacenter. The geographic area within which an EMSagency or health care facility provides service.

Statewide EMS system - a network of local EMSsystems, integrated and coordinated at the statelevel.

Transfer agreement - a written agreementbetween health facilities providing reasonableassurance that transfer of patients will be effectedbetween health facilities whenever such transfer ismedically appropriate, as determined by theattending physician.

Transport time - the interval of time required foremergency medical transport of an ill or injuredperson from the scene of an emergency incident toarrival at a receiving facility.

Trauma care system - a subsystem within the EMSsystem designed to manage the treatment of thetrauma patient.

Trauma Center or designated trauma center -means a licensed hospital, accredited by the JointCommission on Accreditation of HealthcareOrganizations, which has been designated as a LevelI, II, III, or IV trauma center and/or Level I or IIpediatric trauma center by the local EMS agency.

Trauma Resuscitation Area - means a designatedarea within a trauma center where trauma patients areevaluated upon arrival.

Appendix C: Definitions, cont.

Under Triage - Under-triage includes high riskpatients that are transported to a non-trauma centeror that go unrecognized as a high risk patient at atrauma center.

Trauma Service - is a clinical service established bythe organized medical staff of a trauma center thathas oversight and responsibility of the care of thetrauma patient. It includes, but is not limited to,direct patient care services, administration, and asneeded, support functions to provide medical care toinjured persons.


Appendix D: Best Practice Survey Summary Chart

Location Leadership Structure Triage SystemContra Costa County, CA (Best) Trying to model after SD County

(Better) Policies/procedures/standards – meet monthly to review those for under and over-triage; bi-county meeting every other month (with Alameda), meet with trauma center every month; working to use Alameda standards, then eventually SDC standards for review of triage through MAC process

Florida (Better) Strong commitment from trauma community, including trauma surgeons, program managers, state level

(Better) Very specific statewide standards and grant funding to look at under- and over-triage

Los Angeles County, CA (Best) A Trauma Hospital Advisory Committee with multidisciplinary membership provides ongoing evaluation of all elements of the trauma system

(Best) Periodic reevaluation of triage criteria recently included creating a chart comparing the triage criteria of all CA trauma systems

Maryland (Best) Have an independent state agency with regulatory and statutory authority; also an 11-member EMS board that answers directly to the governor; trauma is part of the state's EMS system

(Better+) Believes there is no perfect triage system in existence, but they do have statewide protocols, monitoring through the trauma registry, and a system of feedback between individual hospitals and prehospital providers

Orange County, CA (Best) County has a Trauma Operations committee attended by the EMS Medical Director, EMS Program Manager, EMS Trauma Coordinator, and the Trauma Program Managers and Trauma Medical Directors of the county’s three trauma centers

(Best)

Oregon NR (Better) Data from paramedic triage is sent to a central point in real time

Santa Clara County, CA NR (Better) Triage criteria are standardized and published; adopted from national standards with occasional modifications; looking at having a workgroup

Washington State (Best) Have governor-appointed EMS and trauma steering committee with multidisciplinary membership of about 30, including prehospital, law enforcement, etc.; leadership is also provided by the Department of Health, Trauma and EMS Division

(Better) Have system-wide triage tool, destination protocols and trauma-specific treatment guidelines


Appendix D: Best Practice Survey Summary Chart, cont.

Location EMS Provider Integration Definitive and Rehabilitation Care

Contra Costa County, CA (Better) One of the trauma MDs is going around to prehospital providers, teaching and asking about trauma triage; collaboratively done; MAC meeting every other month, with policy revisions being considered – all providers are invited to those

(Better) Trauma center is not ACS accredited; does have rehabilitation; does a very good job, but she’s not aware of details of their best practices; an example of their commitment to innovative patient solutions is that they found rehabilitation for a South American patient in his home country, and made all the necessary arrangements

Florida NR (Better) Standards exceed ACS requirements; out-of-state specialists do on-site visits; there is a lot of follow up between trauma centers and rehabilitation care providers

Los Angeles County, CA (Better) All policies go through committee process including prehospital involvement

(Best)

Maryland (Best) Trauma is integrated into EMS training and protocols; prehospital providers also participate in case review with hospitals, sit on committees, etc.

(Best) Have a state process for designation/accreditation meeting or exceeding ACS standards; have statewide standards for transfers; have specialty centers (e.g. for hand care, burn care)

Orange County, CA (Better) Strong coordination at the trauma center level to provide jointly sponsored educational programs

(Best)

Oregon (Better/Best) Paramedics have been involved in the system’s design and protocols from the very beginning

( ) Oregon’s creation of the Level IV trauma center designation allowed rural hospitals that formerly would not have become trauma centers to do so; Level I trauma centers send staff to assist rural Level IVs

Santa Clara County, CA (Better) Working to improve integration with quality review system, including greater EMS participation in pre-audit screening and the audit committee

(Best) Meeting ACS standards and moving beyond to do follow-up through the trauma registry on outcome and rehabilitation within a year or two after injury (e.g. by looking at a score in the registry showing improvement after rehabilitation)

Washington State (Better) Prehospital providers are represented on all advisory committees; the Licensing and Certification Committee advises the state on all EMS policy; additionally, there is prehospital involvement on the eight regional steering groups

(Best) Separate designations for general care, pediatric care and trauma rehabilitation, with standards are based on ACS standards; written transfer guidelines are in place



Location Information Systems Quality Review SystemContra Costa County, CA (Best) Just updated to brand new system;

can work collaboratively with trauma center, with both sides accessing and entering data, running reports; registry can and will include prehospital data once it’s determined what it should be

(Best) QI conducted through trauma registry and trauma log, at MAC and bi-county meeting

Florida (Best) All trauma centers are in 100% compliance with registry reporting requirements; key is having a dedicated person or two to work closely with the trauma centers

NR

Los Angeles County, CA (Better) All patients transported to a trauma center are included in the trauma registry; data dictionary tells users how to enter data, and also how to extract it; periodic audits are used to promote excellence; registry data fields are changed when entries are inconsistent

(Best) A subcommittee under the Trauma Hospital Advisory Committee supplements the QI efforts of the region’s trauma centers

Maryland (Better+) Have a state trauma registry, and all hospitals use same software; State Trauma Improvement Council uses registry data to review

(Better) Case reviews are done at the local level; each trauma center is required to have ongoing trauma QI; at the state level, they review registry data, including death and disability, and perform recertification of trauma centers every five years

Orange County, CA (Best) The same program is used for data tracking at all three trauma centers and the EMS agency

(Best)

Oregon (Better) Statewide integrated software system with clear entry and output standards; data from statewide trauma registry are available for County operations, and are used to produce findings

NR

Santa Clara County, CA (Better/Best) Well established trauma registry with emphasis on relevant data and trauma center data downloaded to central point

(Best) Developing outcome database to determine potentially preventable deaths; looking at trends; moving beyond registry data; looking at impact of changes in policies and protocols using database support, with conclusions that are statistically valid

Washington State (Best) Prehospital personnel leave run sheets at the hospital, so data is linked with patient's hospital data in the statewide trauma registry; work is being done on a comprehensive EMS registry (one not exclusively for trauma)

(Better) There are eight regions responsible for multidisciplinary system QI; each designated service is required to have QI; the state uses the trauma registry for mainly hospital QI; each county's medical program director performs prehospital QI



Location Public Education/Outreach Trauma ResearchContra Costa County, CA (Best) Trauma center has full-time RN

dedicated to injury prevention; it has long been recognized as outstanding in the community

NR

Florida (Best) Excellent programs done at the discretion of the trauma centers

NR

Los Angeles County, CA NR (Best)Maryland (Better+) Very active in this area; all trauma

centers are expected to do community intervention and education for trauma; the state division of the ATS is very active and also leads programs

(Better) The National Study Center and the School of Medicine at the University of Maryland work on multi-center studies of system issues, along with the Johns Hopkins School of Public Health, which provides epidemiological data

Orange County, CA (Better) All trauma centers are very involved in prevention programs at the local level

NR

Oregon NR NRSanta Clara County, CA NR (Best) Two Level I’s are both involved in

trauma research; additionally, there are surgeons on sabbatical working on research, in some cases with the EMS agency; a comparison of transports is being conducted in collaboration with other counties

Washington State (Best) Each of eight regions has a program and a staff specialist for this component, and the state level works with them to look at data; individual hospitals are required to have their own injury prevention programs, with Level I and II centers required

(Best) Harborview is a Level I with a highly regarded Injury Prevention Research Center



Location Legislation and System Financing Other

Contra Costa County, CA (Best) Do get grants from the government; the trauma center has its system so well-tuned, it’s functioning well on its own; excellent dedicated trauma social workers; they do what they need to do, get patients placed as needed (for example, South American placed in his home country for rehabilitation)

No specific other practices; however, there is an emphasis on the collaborative nature of the system, with the EMS agency and the trauma center working together as well as with prehospital/fire/ambulance companies

Florida NR NRLos Angeles County, CA NR System in place to compensate private

trauma hospitals for care of indigent patients (funding from a combination of Prop 99, other trauma care funds, SB612 funds, and supplemental funds from the Board of Supervisors)

Maryland (Better) Operational aspects of the system are well-funded (e.g. oversight, training of EMTs)

The state agency has a very good (and frequent) working relationship with trauma program managers and medical directors; they try to use consensus-building for regulation and standards; there is an outstanding communications system based on a state-run EMS and trauma communications center that is able to perform tasks such as tracking occupancy rates of all hospitals (e.g. ORs full, critical bypass), advising on destination, etc.

Orange County, CA (Best) Each trauma center is audited as to how public funds have been utilized prior to distribution of additional funding

Oregon NR The referral pattern from Level IIIs and IVs is very strong

Santa Clara County, CA (Better) Use SB12 to make sure trauma centers get reimbursement; the EMS agency is very supportive in assuring the trauma centers get funding and it is working with the trauma centers on their proposed budget

A lot of energy goes into ensuring that the trauma registry is useful to users as well as the system in general; there is an annual users meeting; there is an annual system report that is 1) directed toward the educated layperson as well as the health care provider and 2) anticipated to soon include information about research being conducted at the trauma centers; finally, the EMS agency has taken an active role in the management of MCIs

Washington State (Best) Relatively stable state trauma fund; funding from surcharges on vehicle licensing and traffic violations; matching of state with federal funds for trauma centers, with grants providing additional funding to hospitals that treat Dept. of Health Services patients and patients with a high ISS

Individual regions are responsible for planning and determining needs for prehospital/hospital trauma care; there are grassroots efforts and buy-in at the local level; prehospital providers are actively involved in planning/standards; trauma center designation is inclusive, including level V trauma centers, with almost all hospitals designated (except in King County, where designation is exclusive)


Appendix E: Comparison of Trauma Triage Criteriafor California Trauma Systems - Prepared by theLos Angeles County EMS Agency, Nov. 2001.Comparison of Triage Criteria Throughout California (by the Los Angeles County EMS Agency)November 2001

Region Definition of Child Adult B/P < 90 Child B/P Respiratory Rate

< 10 or > 29 GCS RTS

Alameda County XX (No Limits

Specified)X X = 12

Any Component = 3

Coastal Valleys Child = < 15y X< 7y/ < 70 7-15y/

< 80X = 13

Contra Costa County

Uses CRAMS = 7 or > 7 w/major

injuries

Fresno, Kings, Madera

X or S/S of ShockX No Limits

SpecifiedX = 13 X = 14

Inland Counties X = 12 X = 12

Los Angeles County

Child = < 14y X X < 70 X BH w/ = 14

Marin County Child = < 14y X X X = 13

Northern Cal Child = < 14y X X < 7y/ < 70 7-

13y/ < 80X X = 13

Orange County X or HR < 50 or > 130

X < 70 X < 12 or > 30 X BH w/ < 12

Riverside County X "Hypotensive" X "Hypotensive" X "Compromise" X = 13 or child = 10

X = 10

Sacramento County

XX No Limits

SpecifiedX X < 14

San Diego County Child = < 14y X X < 60 X X < 14

San Francisco County

X or S/S of Shock X X < 13 X < 11

Santa Barbara County

Child = < 6y X X < 6y/ < 70 X < 14

Santa Clara County X

X = 6y/ < 60 > 6y/ < 90 X X = 13

Sierra-Sacramento Valley

X X X < 14 X < 11

X = Meets Trauma Center Criteria; C = Consideration for Transport to a Trauma Center

Physiologic Criteria


Appendix E: Comparison of Trauma Triage Criteriafor California Trauma Systems - Prepared by theLos Angeles County EMS Agency, Nov. 2001.Triage Criteria Comparison (Cont.)

Region

All Penetrating Torso, Head,

Neck, & Groin

Significant Blunt Trauma of the

Head, Neck, or Trunk

Open or Depressed Skull

Fracture Flail Chest

Diffuse Abdominal

Tenderness Pelvic Fractures

Penetrating Injuries Proximal

to the Knee or Elbow

Alameda County X C X

Coastal Valleys X Including Pelvis X Including Pelvis X X X X

Contra Costa County

X Including Pelvis C Including Pelvis C


X Excludes Groin

Inland Counties X Excludes Groin X X w/Blunt TraumaX All Extremity

Injuries w/Vascular Deficit

Los Angeles County

X SW to chest if between MCL

X X

Marin County X Excludes Groin X X X

Northern Cal X Excludes Groin X X X X

Orange County X X C

Riverside County X Excludes Groin X XX "Firm or Rigid

Abdomen"

Sacramento County

X Including Pelvis X X X

San Diego County X X XX All Extremity

Injuries w/Vascular Deficit


X Excludes Groin

X Including Pelvis

X X


X SW to chest if between MCL

X

Santa Clara County

X X X X


X X X X


Anatomic Criteria



Region

Proximal Long Bone Fractures =

2

Amputation Proximal to the

Wrist or Ankle Traumatic

Paralysis Penetrating

Traumatic ArrestMajor Burns w/

Trauma Patient at the Age Extremes

Precarious Medical History

Alameda County X X X

Coastal Valleys X X XX = 15% or Face

&/or AirwayC < 5y or > 55y C

Contra Costa County

X X X X If ETA is brief X C


X

Inland CountiesX or High

Probability of Spinal Fx

X If ETA is brief

Los Angeles County

X Spinal Injury w/Neuro Deficit

X w/Penetrating Torso

C C

Marin County X X X X

Northern Cal X X XX > 15% or Face

&/or AirwayC < 5y or > 55y C

Orange County X Femurs OnlyX Spinal Injury w/Neuro Deficit

X w/Penetrating Torso

C < 5y or > 60y C

Riverside CountyX or Single

Femur FxX X

X If < 8 min difference in ETA between Base &

Trauma

X C < 5y or > 55y C

Sacramento County

X X X XX = 18% or

Electrical BurnX

San Diego County X X X X C < 5y or > 55y C


X X X X Or Airway C < 5y or > 55y C


X If < 8 min difference in ETA between Base &

Trauma

C < 5y or > 55y C

Santa Clara County

X Femurs Only XX Spinal Injury w/Neuro Deficit

X < 20%=TC > 20%=TC / Burn

Center C < 14y or > 55y C


X X X X


Anatomic Criteria (Cont.)



Region Falls

High Speed Vehicular

CrashesMajor Vehicle

Damage Vehicle Rollovers PSI

Alameda CountyC =15 ft or > 10 ft if =14 y or =55 y

C C w/o Restraints C > 12 in

Coastal Valleys X > 20 ft X > 40 mph X > 20 in X w/o Restraints X > 12 in

Contra Costa County

C =15 ft C = 40 mph C C w/o Restraints C > 12 in


C = 20 ft

Inland Counties X > 20 ft X > 30 mph X

Los Angeles County

X > 15 ft X

Marin County X > 20 ft X X > 20 in X w/o Restraints X > 12 in

Northern Cal X > 20 ft X > 40 mph X > 20 in X w/o Restraints X > 12 in

Orange County C > 15 ft C > 40 mph

Riverside County X > 10 ft C > 20 in X C > 12 in

Sacramento County

X > 20 ft

San Diego County X > 15 ft or 3x patient's height

X > 40 mph X X w/o Restraints X > 12 in frontal or 8 in side


X > 20 ftX > 40 mph or Velocity change

of > 20 mphX > 20 in X X > 12 in


Santa Clara County

X > 15 ft or > 10 ft for Pediatric Pt.

X > 35 mph X > 20 in X w/o Restraints X


C > 20 ft C > 40 mph C > 20 in C C > 12 in


Mechanism Criteria



Region Extrication EjectionDeath in same

Vehicle

MCA >20 mph or separation of

bike & rider

Auto vs Pedestrian or vs

Bicycle

Alameda County C > 20 min C CC = 20 mph or =14y or =55y

Coastal Valleys X > 20 min X X X X > 5 mph

Contra Costa County

C No time C CC > 15 mph or <14y no mph


C Non-amb w/potential sig. injury no mph

C Non-amb w/potential sig.

injury

Inland Counties X > 30 min XX w/injury or

complaintX > 10 mph

Los Angeles County

C No time CC w/injury or

complaintC

Marin County X "Prolonged" X X X > 5 mph

Northern Cal X > 20 min X X X X > 5 mph

Orange County C > 20 min C CX > 20 mph or

thrown 15 ft

Riverside County X > 20 min X X X X

Sacramento County

X > 20 min X X X > 5 mph

San Diego County X X X > 5 mph


X > 20 min X X X X > 5 mph


Santa Clara County

X "Prolonged" X X X X > 5 mph


C > 20 min C C C C > 5 mph


Mechanism Criteria (Cont.)

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Tel: 925.933.0911 Fax: 925.946.0911Toll Free: 1.888.EMS.0911

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