Seeking Legislative Change for Ohio’s Trauma System

Why?

Growing understanding that current system has not resulted in hoped for improvement in outcomes and the widespread belief in the trauma community that we can do better

Well functioning trauma system should be able to show decreasing mortality rate by 10 years

Cost of Fatal Injuries, Both Sexes, All Ages, Ohio, 2005

TotalDeaths 6,502Medical Cost Average $9,311

Total $60,543,000Lost Work Cost Average $937,991

Total $6,098,819,000Combined Cost Average $947,303

Total $6,159,362,000

CDC, WISQARS Database

Cost of Non-Fatal Injuries, Both Sexes, All Ages, Ohio, 2005

Medical Cost $1,557,756,700Lost Work Cost $2,092,567,600Quality of Life Cost $11,961,935,000Total Cost $15,612,259,300

West Virginia University Injury Control Research Center

Problems with Current Legislation EMS Board is the official Lead Trauma Agency for Ohio Current law requires only verification of trauma

centers by ACS Current law does not allow the state to develop a

system for designating trauma centers Current law does not provide for personnel to manage

the trauma system on a day to day basis Current law requires that public reporting of trauma

system outcomes be risk adjusted in all instances Current application of state sunshine law does not

allow for confidentiality of quality improvement activities

Current law does not address non-trauma centers’ role in trauma system

Why Now? Interested Party meeting on merging EMS and Medical

Transportation Boards Trauma representatives objected to the proposal because

of loss of what was already thought to be inadequate representation on the EMS Board to accomplish necessary changes in trauma system

An “Ah Ha” moment for the legislators and governor’s representative Trauma had just been “stuck onto” EMS Board by prior

legislation Didn’t really fit EMS Board’s primary mission▪ Opinion corroborated by many of the other attendees

Hampered the improvement in the trauma system Senator Widener requested that Drs. Jon Saxe and Steven

Steinberg bring recommendations for new legislation to them

Process Meeting Monday, February 18, 2013 in Columbus Trauma experts from around state – including pediatric,

nursing, and EMS representation Utilized the last several years of work – Trauma Framework,

NHTSA report, Tim Erskine’s (ODPS) Strategies and Indicators Document, etc.

Developed some idea for legislative change ACS State Trauma System Consultation Series of meetings with expanded group of trauma

experts and Trauma Visionary Subcommittee (of Ohio Trauma Committee)

Discussions with key stakeholders – leadership of Division of EMS, leadership of ODH, OHA, legislators, governor’s representatives

Legislative RecommendationsA. Mandate ODPS to put out an RFP for a private foundation to manage the State

of Ohio’s Trauma System and be the State’s Lead Trauma AgencyB. The Foundation will be governed by a Board, which will be responsible for all

Foundation activities, including all of the below as well as hiring the key personnel detailed in the State Trauma System Administration slide

C. The Board will be the designating lead agency for trauma in the State of OhioD. Develop a system to designate hospitals as trauma centers

1. All trauma centers must undergo and pass the verification process of the American College of Surgeons Committee on Trauma

2. Clause D.1. will be voided if the Foundation ever develops its own verification process

3. Develop criteria and an application process for designation, re-designation, de-designation, voluntary withdrawal of trauma center status, re-activation of trauma center status, and an appeal process

1. These processes, except for the end result, will be confidential between the Foundation and individual hospital

2. The Board, at its discretion, may designate Level III Trauma Centers that meet the vast majority of ACS-COT verification requirements

4. Define how enforcement will be carried out

Legislative RecommendationsE. Develop a system to allow hospitals provisional trauma

center status as they go through the designation processF. The foundation will have rule making authority over the

Trauma System (this may not be possible due to constitutional limitations) (rules for rule making)

G. Have a trauma system grant section to both administer grants, research and otherwise, as well as seek them

H. Develop a state-wide system for quality improvementI. Develop a state-wide system for injury preventionJ. House and manage the state trauma and rehabilitation

registries1. A single patient identifier system will be developed

K. Provide trauma related education to health care providers in the pre-hospital and hospital settings to include both trauma and non-trauma centers

Other Legislated Functions1. Require an annual public report on the status of the State’s Trauma System2. The foundation will be allowed to charge and collect an annual fee from all

hospitals and free standing emergency departments. A method of graduated charges will be developed.

3. Develop formal linkage to the regional trauma organizationsi. Develop minimum requirements to be recognized as a regional trauma

organizationii. Develop budget for funding each qualified regional trauma organization

4. All hospitals and free standing emergency departments must participate in the foundation

5. The foundation will develop an INCLUSIVE trauma system to include all entities that care for trauma patients (Definition: An Inclusive Trauma System recognizes and has a place for all groups and institutions that play a role in trauma care or prevention including injury prevention specialists, pre-hospital care providers, trauma and non-trauma centers, and rehabilitation facilities)

6. Quality information and discussions protected7. All meetings will be open but do not need to be in person8. Committees and Board may go into executive session9. Eliminate the current Ohio Trauma Committee of the EMS Board10. Reduce trauma representation on EMS Board to 1

Board Composition

1. Trauma surgeon from each of the identified regions2. At least one pediatric trauma surgeon3. Trauma program manager from each of the identified regions of the state4. At least on pediatric trauma program manager5. Two hospital administrators from Level I or II trauma centers6. Two hospital administrators from non-trauma centers7. Two hospital administrators from a Level III trauma center8. Representative of the Ohio Committee on Trauma9. One rehabilitation physician10. One orthopedic trauma surgeon11. One neurosurgical trauma surgeon12. One emergency medicine physician13. A certified registrar14. An injury prevention expert from ODH15. A pre-hospital provider from the EMS Board16. An at large lay person17. A trauma victim advocate from the Governor’s Council on People with

Disabilities

Requirements of the Board Members1. Number of required meetings per year2. Definition of who can become employed3. Criteria for Board members:

i. Ageii. Resident statusiii. Length of appointmentiv. Filling vacanciesv. That they are Governor Appointmentsvi. Oath of Officevii. Per Diems; expenses and mileageviii. Election of Chairix. Duties of Officers

4. Establish an office

Trauma Executive Director (TPM)

Performance ImprovementCoordinator

Injury PreventionCoordinator

Trauma RegistryCoordinator*

TraumaEducation

Coordinator

Administrative AsstTrauma Medical Director

AccreditationCoordinator

Trauma Regional Care

Coordinator

Grants Administration

Coordinator

Epidemiologist* Biostatistician*

Registrar*Region A Coordinator

Region B Coordinator

Region C CoordinatorRegion D

Coordinator

Region A Medical Director

Regional BMedical Director

Region C Medical Director

Region D Medical Director

Registrar*

ACS Recommendation Positions

* Current State-Funded Position

State Trauma System Administration

EMSIRS

Region ECoordinatorRegional F Coordinator

Region EMedical Director

Region FMedical Director

(number and geography of regions to be determined)

State Trauma Board

State Trauma Administration

Accreditation Coordinator

Responsible for the implementation, coordination, tracking and documentation of the hospital accreditation process in accordance with established standards, policies, and procedures.

Trauma System Executive Director (TPM) Provides overall program leadership in collaboration with the Trauma Medical Director to establish, maintain and improve a comprehensive trauma system including the full trauma spectrum from injury prevention, prehospital , hospital and rehabilitation services. Manages staff, operations, and budget to facilitate program performance.

Trauma Registry Coordinator*

Manages the state trauma and rehab registries.

State Trauma Board

Regional Medical Director **

Provides oversight of compliance with trauma care guidelines at the regional level, conducts PI initiatives as indicated, communicates directives from the state and enhances to coordination of trauma care by establishing relationships and communications with EMS Medical Directors and Hospital representatives.

Regional Coordinator **

Works with hospitals, Injury prevention, EMS and rehab facilities to form a network for regional trauma systems, promote communication, collaboration and integration of services, collaborates with regional medical directors to work on direct-ives, represents the region for the state.

Trauma Education

CoordinatorDevelops, coordinates and provides oversight for trauma related education to healthcare providers in the pre-hospital and hospital settings to include both trauma and non-trauma hospitals.

Grants Administration

CoordinatorResearches, identifies, writes and administers grants for funding, to support trauma system program activities.

Injury Prevention

Coordinator Develops and provides oversight of statewide program for injury prevention.

Performance Improvement Coordinator

Develops and provides oversight of statewide program for Performance Improvement activities.

Biostatistician*Analyze data for clinical quality studies to improve delivery of trauma patient care throughout the spectrum including injury prevention, prehospital care, hospital care, and rehabilitation.

Epidemiologist *Collaborates with Injury Prevention Coordinator, PI coordinator and Trauma Registry Coordinator, to assess main outcome measures including Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism.

Registrar*

ACS Recommendation Positions

* Current State-Funded Position

** Regional Medical Director/Regional Coordinator Team for each region as advised by the State Trauma Advisory Committee

Registrar*

RC x 3-5

Trauma Regional Care Coordinator

Develops formal linkage to the regional trauma organizations; develops minimum requirements for regional trauma organization; and develops budget for funding each qualified regional trauma organization. Provides the infrastructure for bidirectional communication between the state and regional trauma organizations to improve system-wide coordination of trauma care. EMSIRS

RMD x 3-5

Trauma Medical DirectorProvides overall medical program leadership in collaboration with the Trauma Systems Executive Director to establish, maintain and improve a comprehensive trauma system throughout the full trauma spectrum of care (injury prevention, prehospital , hospital and rehab services).

Projected Operating Expenses

REVENUE (assuming a fee and expense structure similar to COTS)

Funding From Hospitals (COTS Fee Schedule, for illustration purposes only)• Trauma Centers = 46 @ $22,000 = $ 1,012,000• Non Trauma Center Hospitals/Free Standing ED= 161 @ $2,000 = $ 322,000

Total = $ 1,334,000

EXPENSES• Staff Development $30,000 (1.5 X COTS) = $ 45,000• Supplies/Postage Mailing $26,000 (x 4) = $

104,000• Professional Fees $72,000 (x2) = $ 144,000• Occupancy $79,000 (x1.5) = $

118,000• Marketing/Advertising $75,000 ( x 1) = $

75,000• Shared Admin $29,000 (x1.5) = $

36,000• Salaries and Benefits projected =

$2,699,925 Total = $3,221,925

Revenue – Expenses = (NET) (- $ 1,887,925)

Budget

Expense will be ~$3,200,000 It is reasonable to expect trauma centers to provide some

support as most of them already support regional trauma organizations If COTS’ fee schedule is used=$1,012,000

Many small rural hospitals operate on a very small margin We recommend against requiring them to pay toward the system

although a voluntary fee structure could be set up to allow donations

The Foundation should be charged with seeking funds from other sources including grants, endowments, donations For every $1 of money raised that can be used for operational

expenses (e.g. Grant money, interest from endowment), there would be a $0.50 reduction in the amount of support from the state

Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc.

Open forum for diverse (and otherwise competitive!) groups to come together – EMS, Trauma centers, Non-trauma centers, doctors, nurses, etc.

Regional educational programs – ATLS, Emergency Nursing Pediatric Course (ENPC®), the Trauma Nursing Core Curriculum (TNCC®) Course, and others

Regional guidelines/protocols Burn surge plan, Regional mass movement of patients plan, Trauma alert

criteria, Patient destination guidelines for multiple and mass casualty situations, Prehospital triage guidelines, Law enforcement & Hospitals: Carrying and Relinquishing Firearms, Regional Guidelines for Patients with Concealed Weapons, Regional Guidelines for Activation of the Surgical Emergency Response Team (SERT), Regional Guidelines for Acute Care Hospitals Trauma Performance Improvement, Regional Guidelines Regarding Patient calls To EMS for Transport from one Hospital to another hospital

Annual benchmarking reports and datasets for research

Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc.

COTS Bridges The Gap Between Diverse Health Systems And Institutions To Advance Regional Process Improvement Providing assistance/education to trauma centers and acute care hospitals

within the region, providing a forum to improve communication lines among Trauma Medical Directors, ED Medical Directors and EMS Medical Directors, serves as conduit between agencies providing care to the injured patient, identifies standard of care outliers and offers recommendations, provides consultative reviews for trauma care protocols and trauma patient transfer agreements (ORC 3727.09), provides surgical expertise for pre-hospital protocols and issues, serves as consultant for EMS peer review and quality assurance programs/issues (ORC 4765.12)

Advocacy and other Legislative Activity Enforcing stricter penalties for texting while driving, improving accessibility

to influenza vaccination for vulnerable populations by expanding EMS scope of practice, supports and actively engages in legislative initiatives to improve emergency care and injury prevention programming in Central Ohio

Manages regional trauma registry

Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc.

Maintains the Hospital Emergency Departments’ Real-time Activity Status System (RTASS) to document incidents of EMS diversion and how busy EDs are in real-time. The system allows hospitals to immediately notify EMS when their EDs are overly busy or on divert status.

Provides hospitals educational opportunities including certification courses (i.e. ATLS, TNCC, ENPC etc), annual trauma research symposiums, guest speakers and other classes upon request (i.e. CEN Review and trauma data management courses)

On hospital request, attends Joint Commission Hospital Review to lend support and information demonstrating the hospital’s collaboration with other hospitals and healthcare entities on regional and statewide initiatives including disaster preparedness planning and exercising, shared services agreements, regional and state burn plans, regional and state pediatric surge plans and other regional healthcare improvement initiatives

Serves as an organization to deal with other time critical diagnoses, including stroke and STEMI