History of Trauma System Development in California

1
History of Trauma System Development in
California

• David Hoyt, MD, FACS
• Professor and Chairman
• Department of Surgery
• University of California, Irvine
• Orange, California

2
18th 19th Century Health Care Delivery

• House calls
• No rapid treatments
• Kitchen table surgery

3
18th 19th Century Hospitals

• All admissions needed approval
• Patients were refused admission
• Incurable
• Cancer
• Epilepsy
• Contagious
• Smallpox
• Could not pay
• Paupers sent to almshouse
• Not worthy of admission
• Conditions of immorality
• Prostitution/STDs
• Alcoholism
• Unwed mothers

4
Where Did Emergency Patients Go?

• The Receiving Hospital
• A hospital that would receive all emergency
  patients
• Los Angeles City Receiving Hospital System
• Received ambulance cases
• Transferred to County General or other Hospitals

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Early Hospital Emergency Care

• Emergency Room or Accident Room
• Cared for people who had no place else to go

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Admission log - Los Angeles City Receiving
Hospital

• April - June 1908
• 7.3 patients/day

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The Patients Situations of 1908

• Trauma
• Pedestrian vs. Streetcar
• Traumatic arrest
• Horses
• Bites, kicks
• Horse fell on him
• Bar fights
• Knifes, bottles, fists
• Automobiles?
• Minor cuts bruises
• Industrial injures
• Cuts, crush, amputation
• Burns - nitrate movie film

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The Patients Situations of 1908

• Social problems
• Child abuse
• Hit by father with board
• Spouse abuse
• Beaten by husband
• Suicide
• GSW head, chest
• Potassium permanganate

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The Patients Situations of 1908

• Abortion
• Refused to give doctors name
• Addictions
• Alcohol
• H.B.D.
• H.B.D.V.M.
• Opiates (morphine)
• Tx Coffee (caffeine) into gastric tube

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The Patients Situations of 1908

• Asthma
• Tx Chloral Hydrate Strychnine (stimulant)
• Cardiac arrest
• Tx Adrenaline
• Sexuality issues
• Gonorrhea suppression of urine
• Injury to perineum
• Slipped on apple
• How injured masturbation
• Treatment Bedrest

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Early Hospital Emergency Care

• Hospital Emergency rooms staffed by
• Doctors without a practice
• Doctors working overtime
• Emergency Medicine - 1971

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Emergency Nursing

• Triage - emergency nursing

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The Hoover Commission

• 1923 -Secretary of Commerce
• Reviewed the mortality crisis with the automobile
• 20,000 deaths/year
• Results
• Sweeping recommendations
• Roads, traffic safety, licensing
• No call for care systems

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Ambulances Emergency Transport

• Began in War Time
• Walt Disney served in WW I - France

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The Early Ambulance Experience

• Earliest focus was on safe, comfortable trip
• Why Rush to the hospital?
• No emergency treatment on arrival
• No defibrillation or trauma surgery
• 1920s California Vehicle Code
• After a collision . . . transport the injured in
  whichever vehicle still operates . . .

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Who Operated Most Ambulance Services?

• Adopted by Funeral Services
• Had a vehicle that could transport a body in a
  supine position
• Could gain goodwill in community

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Who Operated Our Ambulances?

• Some Los Angeles area companies

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Local California Dispatch

• 1969 Automobile club study
• 70 different ambulance phone numbers servicing
  a 26 mile section of San Diego freeway

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Californias Original Minimum Ambulance Training
Requirements

• One crewman must have Red Cross Advanced first
  aid card
• Other attendant (within 15 days of employment)
• Enrolled in basic first aid class
• Complete advanced first aid class within 90 days.

22
Ambulance Documentation Billing

• Most documentation related to costs/charges
• Taxi meters would assure accurate fees

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Mass Casualty Incident - Pre-EMS

• August 1, 1966
• University of Texas Austin
• Sniper - Charles Whitman fired from top of 27
  story clock tower
• 15 killed
• 31 wounded
• Six funeral homes sent 13 ambulances

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Documentation and Billing -1966

• No victim names taken
• No charting
• No Funeral Home billed for ambulance transport
• That night the same funeral homes that sent
  ambulances transported the dead for their final
  services
• In hearses NOT ambulances

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Trauma Magnitude of the Problem

• 1966 -The neglected epidemic

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What Changed

• A pre-hospital curriculum
• Pre-hospital Care became a profession
• 1970-72

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Emergency

• In 1972 the TV show Emergency debuted
• The Jack Webb creation

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1970-1980

• Developing local Trauma Systems
• Los Angeles EMS
• Orange EMS
• San Diego EMS
• Santa Clara EMS

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1980

• Development of Californias State EMS Leadership
• State law added Division 2.5 of the Health
  Safety Code
• Established the Emergency Medical Services
  Authority
• LEMSA Model Started

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1983

• Trauma Systems added to the Health Safety Code
• Allow, but not require, development of local
  trauma care systems
• System based upon a series of local, optional
  trauma care systems

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1986

• Trauma care regulations established
• California Code of Regulations, Title 22,
  Division 9, Chapter 7
• Trauma Care Systems
• Promulgated to provide minimum standards for
  local trauma systems locally designated trauma
  centers

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Trauma SystemA Public Private Partnership
Scripps Mercy
Sharp Memorial
Palomar Medical Center
County Health EMS
Scripps Memorial
Childrens Hospital
UCSD Medical Center
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Trauma CenterCommitment

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

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Trauma Center Standards

• Trauma Center
• Designation standards
• Data collection
• Quality improvement protocols

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San Diego County

• CNS Non CNS- 1982
• 12/90 Preventable Deaths
  (Amherst Study)
• System--------------1984
• 1984
• 3/112 (3m) Preventable
• 1986
• 11/541 Preventable

Current rate lt 1
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Significant Accomplishments

• Paramedic Training
• Regional EMS systems
• 911
• ATLS
• Trauma Care standards
• Verification
• National Trauma Data Bank

Disease Management Model
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The Infrastructure
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Started 2005
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The Evidence

• All measurement techniques
• 8-10 mortality reduction

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The National Study on Costs and Outcomes of
Trauma Center Care NSCOT
25 - Mortality Reduction lt55
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The LEMSA Model A Story of Great Success
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Why Not Everywhere
44
Trauma Centers in the United States All Levels
Why not everywhere ?
? Level I II ? Level III-V
Plotted by Hospital ZIP Code
Challenges ???
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Percent of ISS gt 15 Adult PatientsTreated at a
Level I/II Center
Level I/II per Popn of ISSgt15 Treated at a Level I/II
Florida 1.1 56
California 1.2 55
North Carolina 1.1 66
Maryland 1.3 78
Pennsylvania 2.0 63
New York 2.4 69
Illinois 4.9 77
Missing Patients
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1987

• Assembly Office of Research described
  Californias trauma care system
• Medical financial emergency, pointing to
  financial losses experienced by trauma centers
  a need to financially stabilize trauma care
  systems
• Some hospitals (particularly in Los Angeles)
  dropped trauma center designation, citing
  financial losses.

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1980s-1990s

• Closure or threatened closure of trauma centers
  in several areas of the state resulted in media
  attention policy initiatives to increase state
  subsidies or develop alternative funding sources
• Physicians hospitals indicated the root problem
  of emergency trauma care issues was
  uncompensated care

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System Finance
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Threats to Trauma Care
Main Reason All Reasons
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DespiteLegislative Support

• Trauma Systems Reauthorization
• Federal Agenda Inconsistent

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1980s-1990s

• Several legislative proposals to provide funding
  for trauma care surfaced most failed

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1987

• The Legislature enacted Chapter 1240, Statutes of
  1987
• Allowed counties to establish a Maddy Emergency
  Medical Services Fund (Maddy Fund)
• Compensate health care providers (hospitals and
  physicians) for emergency services for the
  uninsured compensate medically indigent
• Ensure the population has continued access to
  emergency care.

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August 1999

• California Regulations were updated

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1999

• EMSA Vision Implementation Project begun

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2001

• AB 430 (Cardenas) established Chapter 171
• Statutes created the Trauma Care Fund a formula
  for distribution of funds to local EMS agencies
  for designated trauma centers

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2001

• California Statewide Trauma Planning Assessment
  Future Direction begun

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October 2003

• Vision Implementation Project Final Report
• Acknowledged System Status
• Provided Standards direction for California
  Statewide Trauma Planning Assessment Future
  Direction

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Process

• Trauma Advisory Committee started to develop a
  statewide trauma system plan in concept

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Problem

• California state law allows for, but does not
  require, development of local trauma systems

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Problem

• State contains 58 counties divided into 31 local
  EMS agencies
• Local trauma systems based on state regulations -
  not mandated
• State EMS Authority
• Responsible for developing statewide standards
  for trauma care systems and trauma centers

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Challenges

• We still lack a coordinated statewide trauma care
  system that provides
• Universal access to essential trauma care
• Coordination of resources amongst local trauma
  systems
• A statewide trauma registry to insure consistent
  information
• Consistent dedicated infrastructure funding

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Other Challenges

• Large geographic area of the state
• Variations in terrain
• Population density
• Ethnic diversity
• EMS cultures
• Weather
• System and financial resources

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EMS Authority 2003-2006

• Did Federal and ACS assessment of current state
  system
• Published
• California Statewide Trauma Planning Assessment
  Future Direction

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September 2006

• Governor Schwarzenegger signed
• California Statewide Trauma Planning Assessment
  Future Direction

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EMSA 2008

• Draft Implementation Plan
• Leadership
• Data
• Funding
• Synthesis of Trauma Advisory Committee and EMS
  Authority

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California Trauma System

• We have all done great things in California
• We are constantly in search of putting ourselves
  out of a job
• Lets go to the next level with our system