The Impact of Including

Level III Trauma Centers in

Pennsylvania16th Annual PTSF/PaCOT Conference

October 25, 2012

Juliet Geiger RN, MSN –Executive Director, PTSFDavid Scaff, DO – Trauma Program Medical

Director, Pocono Medical Center

Historical Background

• 1985 – Standards of Accreditation for Adult L1/2 and Pediatric L1 trauma centers developed

• 1992 – L2 Pediatric Standards developed

• 2004 – Act 15 0f 2004 signed mandating L3 standards be developed

• 2012 – One accredited L3 hospital, two hospitals pursuing L3 accreditation

Level III Accreditation History

Pursuit funding restored

Questionnaire

• Questionnaire sent to eligible hospitals that received pursuit funding and those eligible hospitals that elected not to pursue accreditation in order to describe:– Reasons for pursuing or not pursuing Level III

accreditation– Barriers preventing a hospital from pursuing

accreditation– Barriers to becoming accredited for those that

received funding– Resources that would have helped with pursuit– Factors that would be necessary before pursuing

accreditation in the future.– Outcomes as a result of pursuit effort

Results:Reasons for Pursuing

Accreditation

• Enhanced quality of care • Increased marketing of hospitals to

generate higher volumes of patients

• Receipt of grant funding

Results: Positive Outcomes

• Enhanced level of care of injured patients

• Improved care of all patients within hospital

• Implementing standardized protocols and policies for care of injured patients

• Energized nursing and physician staff in the care of injured patients

• Improved Performance Improvement efforts

County A Injury Mortality Rates

L3 Accreditation 11/1/09

County B Injury Mortality Rates

L3 Accreditation11-1-08

Barriers to Pursuing Accreditation: Surgeon

SupportFeared increased patient volumes and

injury severity

County A (accredited 2009) County B (Accredited 2008)

Barriers to Pursuing Accreditation: Physician

Leadership

• Trauma Medical Director must be a surgeon

• Rural areas predominately have private practice physician groups

• Peer Review process challenging

Barriers to Pursuing Accreditation: Funding

• Administration feared insufficient funding and disappearance of funding.

• In 2010 a two year delay did occur due to the West Virginia lawsuit that delayed trauma funding to all trauma centers and those pursuing accreditation.

Barriers to Pursuing Accreditation: Education

• From PTSF– Education limited to state wide in-

person forums with limited 1:1 visits– L3 inclusion started almost 20 years

after L1/2 trauma centers developed

• From Trauma Centers – Unclear of role and how to support L3

development– Not fully supportive of L3 inclusion in PA.

PTSF Next Steps… • Foster relationship building between higher

level trauma centers and their rural colleagues• Enhance PTSF’s educational approach • Continue Level IV trauma center development• Perform trauma system research geared toward

measuring the trauma center/system value. • Continue to advocate for state and federal

funding of trauma centers• Embark on a public education campaign

Lessons Learned at a Level III or…………

How to boil a frog

• 2 Fellowship trained Trauma Surgeons– 7 at partner level I

• 4 General Surgeons– 1 at partner level I

• 3 Trauma Physician extenders

• Trauma Program Manager

• Trauma PI Coordinator

• Data Analyst/Registrar

• Registrar

• Administrative Support

The Trauma Service at PMC

Demographics - Age

67.4%

n=2784

6.8% 5.9% 11.8% 8.2% 19.0% 17.1% 21.0% 10.3%

Mean age = 52

Demographics

Mechanism of injury

Monroe Co. Trauma Pt’s – ICD 9

45% 55% 35% 65%

Trauma Contacts

Trauma Admissions by Alerts & Consults

75

Projected

30 day Re-admit Rate 0.7%

ISS – PTOS PatientsAis 2005

% Mortality

21791165

The key to Level III success !

Keys to Level III success

• P P -Personnel

• C C -Commitment

• P P -Partnership

Personnel

• Trauma Program Manager

• ED Medical Director

• Trauma Program Medical Director

Personnel

• Trauma Program Manager– Patient care experience – Organized– Resourceful– Relationship builder– Team philosophy– Conflict resolution

Personnel

• ER Medical Director– Committed to trauma development– Relinquish autonomy– Respected by colleagues– Gateway to EMS community

Personnel

• Trauma Medical Director – Identify the “Players”/understand the

culture– Listen : talking ratio 3:1– Inclusive to existing medical staff– Standards of care– Fair to all parties involved– Lead by example– Think outside the box– Be the “Champion”

Commitment

• Board & Administrative Commitment– Long term vision = Long term gains– Start up cost/loss of revenue– Recognize limitations of institution– Recognize trauma involvement is all

areas– Commitment to cultural change– Adequate staffing – MD’s / PA-C’s / NP’s– Ask for help/accept support

Partnership

• Long term commitment / contract• Guidance on trauma service

development• External PI review• Staffing resources• Guideline development• Trauma department resource

Trauma’s “Halo” Effect

“Halo”• Massive Transfusion Protocol• Improved ER triage• Nursing education• Increased blood bank capacity• Development of Performance

Improvement Process• Preparation for the unexpected• Public/Patient Satisfaction• Pride in Institution

Halo Effect - 2009• 22 yo Female, Acute abdominal pain

– BP 85/66, HR 110– Rapid triage– Ultrasound confirmation of significant

abd fluid– Resus begun (Blood & crystalloids)

– To OR in 30mins – Ruptured Ectopic– Home Day 3

– “Thank you, 2 years ago the outcome might not have been the same”

– Kris Farrell, CRNP - ED

Surgeon Involvement

• Challenges:Challenges:– Staffing for 365

coverage– Sustainable life style– Trauma service vs.

independent practitioners

– Disruption of elective cases/office hours

– “Trauma Drop Outs”– Risk exposure/non-payer– Peer Review PI

• Solutions:Solutions:– Extender support

• Day vs. Night vs. Both

– Call stipend– Malpractice support– Partnership staffing– Block time in OR– Post Call non-clinical– Service sign-over– Non-punitive Peer

Review

Emergency Department

• Challenges:Challenges:– We know how to do

“trauma”– Turf battle– Not enough space

for Trauma bay– Mindset: not injured

vs. potential injuries– Performance

improvement

• Solutions:– One call, problem

solution– Back up for airways– Feedback of

outcomes– Highlight good cases– Support of the ED at

administrative level

Financial

• Challenges:Challenges:– Non-payer mix– Call compensation– Non-clinical staffing– Educational costs

• Solutions:Solutions:– Maximize RVU

generation– Improved care =

malpractice reduction– Increased patient

volume– Higher complexity of

cases– Trauma Extenders

support other services

– Halo effect

Orthopedics**

• Challenges:Challenges:– Consultation service– Disruption of elective

schedule/office hours– Staffing for 365

coverage– Risk exposure/non-

payer

• Solutions:Solutions:– Ortho Trauma block

time– Call stipend– Employed group– Recruitment for

private group– Malpractice support– Extender support– Trauma Service

management

Pocono Ortho Surgery- Transfers

Total operative fractures seen: 110, 95

40.9%

23.1%

1.6% 16.3%

5.2%

1.0%

5.4%

Types of fractures transferred

Pocono Ortho Surgery– Time to OR

Average to OR 34hr

Average to OR 18.8hr

Average LOS 4.5Average LOS 5.1

63%

75%

7%

21%18%16%

Summary• Level III’s Impact

– Hospital / Patients / Community

• Right personnel • Full commitment from administration• Partnership for success• High start up cost/Long term gain• Solutions are “institutionally

dependent”• Culture Change is the “Frog”

Thank you!

dscaff@pmchealthsystem.orgjgeiger@ptsf.org