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EMS/Trauma PerformanceEMS/Trauma Performance
Healthcare Safety Net Initiatives Healthcare Safety Net Initiatives ConferenceConference
February 9, 2007February 9, 2007 Charles Begley and Munseok Seo for Charles Begley and Munseok Seo for
the H-GAC Emergency/Trauma Care the H-GAC Emergency/Trauma Care Data CommitteeData Committee
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Project BackgroundProject Background
The H-GAC Emergency/Trauma Care Policy Council created The H-GAC Emergency/Trauma Care Policy Council created 20032003 Members from 13 H/GAC counties in southeast Texas Members from 13 H/GAC counties in southeast Texas Emergency physicians, trauma surgeons, hospital administrators, Emergency physicians, trauma surgeons, hospital administrators,
EMS providers and representatives from the two local trauma EMS providers and representatives from the two local trauma regional advisory councils regional advisory councils
Mission Mission Develop plans and policies for improving regional Develop plans and policies for improving regional
emergency/trauma care emergency/trauma care Create system for monitoring regional performanceCreate system for monitoring regional performance
A data committee was charged to develop monitoring system A data committee was charged to develop monitoring system
HHSRC is supporting this effortHHSRC is supporting this effort
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Data Committee ActivitiesData Committee Activities
Developing integrated database Developing integrated database Hospital ER Visit dataHospital ER Visit data Texas Trauma RegistryTexas Trauma Registry Texas Health Care Information Collection hospital discharge databaseTexas Health Care Information Collection hospital discharge database EMSystem hospital diversion database. EMSystem hospital diversion database.
Monitoring performance indicatorsMonitoring performance indicators Number and type of ER visitsNumber and type of ER visits Hospital hours on diversionHospital hours on diversion EMS response times and triageEMS response times and triage Trauma morbidity and mortalityTrauma morbidity and mortality Changes in trauma system capacityChanges in trauma system capacity Changes in the level of uncompensated careChanges in the level of uncompensated care
Conducting special studiesConducting special studies ED algorithm studyED algorithm study Impact of hospital diversionImpact of hospital diversion Relationship between trauma care capacity and outcomesRelationship between trauma care capacity and outcomes
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Today’s PresentationToday’s Presentation
Monitoring data on: Monitoring data on: Regional hospital diversionRegional hospital diversion
EMSystem data on the latest trends in hospital EMSystem data on the latest trends in hospital diversiondiversion
Morbidity and mortality in Houston hospitalsMorbidity and mortality in Houston hospitals THCIC data on latest trends in trauma cases, THCIC data on latest trends in trauma cases,
morbidity, and mortalitymorbidity, and mortality
Patient triage in Houston hospitals Patient triage in Houston hospitals THCIC data on latest trends in trauma patients being THCIC data on latest trends in trauma patients being
triaged to appropriate hospitalstriaged to appropriate hospitals
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Hospital DiversionHospital Diversion
EMSystems data on hours that hospitals are on: EMSystems data on hours that hospitals are on: Divert: unable to provide level of care demanded by trauma Divert: unable to provide level of care demanded by trauma
patients.patients. Caution: a shortage situation that should be noted but does not Caution: a shortage situation that should be noted but does not
warrant Divert.warrant Divert. ER Saturation: ER heavily saturated and non-critical patients ER Saturation: ER heavily saturated and non-critical patients
will have to wait an excessively long period of time.will have to wait an excessively long period of time.
Examining these data for 2003-06, it is apparent Examining these data for 2003-06, it is apparent that:that: The overall amount of hospital diversion has stayed the same The overall amount of hospital diversion has stayed the same Diversion has gotten worse among Level I hospitalsDiversion has gotten worse among Level I hospitals ER saturation diversion is rising less rapidly than total diversionER saturation diversion is rising less rapidly than total diversion
66
77
88
Figure 2. Hours of Diversion & Caution by Month: Level I Hospitals BTGH & Memorial Hermann (Jan' 03 - Dec' 06)
15.6
20.8
24.6
26.326.8
32.1
50.8
41.2
21.4
27.6
44.3
57.5
20.7
28.5
24.2
25.9
24.0
42.7
40.3
19.2
25.1
35.3
13.9
21.2
49.4
53.5
31.8
22.7
34.3
29.2
22.4
32.0
45.6
29.9
37.4
51.4
67.8
44.4
61.5
57.5
43.7
40.239.0
46.2
42.844.2
46.9
51.2
y = 0.4765x + 24.479R 2 = 0.2607
0
10
20
30
40
50
60
70
80
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
99
Figure 3. Hours of Diversion & Caution by Month: Level III HospitalsCHRIST ST.J, LBJ, MH_NW, MH_SE, MH_SW, Oak Bend (Jan' 03 - Dec' 06)
39.7
36.2
29.7
38.5
40.3
36.9
34.5
44.6
32.6
37.1
40.8
31.0
38.5
24.3
21.9
24.825.1
28.5
34.7
24.424.1
15.415.2
22.4
38.7
53.8
29.8
33.4
23.8
31.6
34.2
40.8
36.036.9
32.0
44.544.2
36.8
27.1
42.0
26.9
18.3
24.2
31.3
26.4
22.2
35.7
29.4
y = -0.0955x + 34.451R 2 = 0.0265
0
10
20
30
40
50
60
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
1010
Figure 4. Hours of Diversion & Caution by Month: Level IV HospitalsDoctors-pwy, East Houston, MH The Woodland (Jan' 03 - Dec' 06)
22.3
17.6
7.7
17.9
13.6
15.4
37.0
21.3
15.615.7
18.619.2
16.9
28.3
14.714.2
19.4
4.0
39.4
7.3
8.7
24.5
11.1
6.3
9.0
23.1
37.8
15.2
0.8
7.0
19.3
6.3
12.5
7.2
13.1
12.1
20.8
16.9
10.1
15.5
10.6
21.5
8.5
6.3
14.014.5
30.6
29.1
y = -0.0775x + 18.119R 2 = 0.0156
0
5
10
15
20
25
30
35
40
45
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
1111
Figure 1. Hours of ER Saturation by Month: All Hospitals Jan' 03 - Dec' 06
3.83.6
8.8
10.6
11.9
8.9
6.8
7.77.6
9.5
5.8
5.5
4.6
6.0
5.3
7.0
4.2
7.6
7.2
6.0
3.9
4.7
3.0
5.3
7.0
11.4
9.8
7.9
10.0
11.1
12.1
9.89.6
11.2
10.5
9.7
8.5
6.3
4.2
8.1
9.7
5.3
6.5
3.7
3.4
8.8
10.7
12.1
y = 0.0348x + 6.7046R 2 = 0.0332
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
1212
Figure 2. Hours of ER Saturation by Month: Level I Hospitals BTGH & Memorial Hermann (Jan' 03 - Dec' 06)
2.5
5.6
10.9
17.2
10.0
8.2
10.4
9.9
9.0
13.7
11.6
6.8
4.5
8.3
5.55.8
1.8
6.7 6.6
3.5
0.5
1.4
0.7
2.8
5.6
19.4
7.7
4.7
9.3
5.7
7.2
12.2
10.8
9.3
12.0
15.3
12.6
6.6
4.6
15.4
16.2
6.9
13.9
4.5
5.0
6.6
8.2
6.9
y = 0.0256x + 7.5142R 2 = 0.0065
0
5
10
15
20
25
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
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Figure 3. Hours of ER Saturation by Month: Level III HospitalsCHRIST ST.J, LBJ, MH_NW, MH_SE, MH_SW, Oak Bend (Jan' 03 - Dec' 06)
3.3
3.8
13.113.1
18.0
13.2
8.8
7.7
9.4
12.0
6.6
8.1
5.6
4.94.6
9.9
7.4
10.4
9.2
8.6
6.6
9.1
4.7
7.3
11.2
12.012.3
10.6
12.3
17.4
18.9
10.8
12.4
18.9
13.8
9.9
11.1
9.1
4.1
8.1
11.8
5.9
5.1
3.63.7
11.0
13.0
13.5y = 0.0224x + 9.1567R 2 = 0.006
0
2
4
6
8
10
12
14
16
18
20
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
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Figure 4. Hours of ER Saturation by Month: Level IV HospitalsDoctors-pwy, East Houston, MH The Woodland (Jan' 03 - Dec' 06)
8.6
2.0
1.6
2.7
1.6
0.8
1.8
2.9
2.5 2.6
1.01.2
2.2
6.3 6.3
2.5
0.2
0.9
0.50.8
0.30.0
0.5 0.50.3
2.1
1.3
0.60.3
0.7
1.8
0.2
1.41.6
2.2
3.5
1.5 1.4
4.2
3.1
2.6
3.1
1.8
3.5
1.7
6.5
7.7
13.9
y = 0.0418x + 1.4199R 2 = 0.0506
0
2
4
6
8
10
12
14
16
Month & Year
% o
f O
pera
tin
g H
ou
rs
SOURCE: emsystem.com
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Mortality and MorbidityMortality and Morbidity
THCIC hospital discharge data from 1999-2003 THCIC hospital discharge data from 1999-2003 Trauma cases are defined by ICD-9 CodeTrauma cases are defined by ICD-9 Code Injury severity is measured by ISS score which is derived Injury severity is measured by ISS score which is derived
using the ICDMAP-90 software developed by MacKenzieusing the ICDMAP-90 software developed by MacKenzie Mortality is defined at dischargeMortality is defined at discharge
Examination of 99-03 trends indicate:Examination of 99-03 trends indicate: The number of Houston trauma cases declinedThe number of Houston trauma cases declined The severity of cases is stableThe severity of cases is stable The mortality rate is rising, particularly for the most The mortality rate is rising, particularly for the most
severe cases severe cases
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Houston Trauma Cases
14,769
15,307
14,566
13,999
13,057
y = -473.2x + 15759
R 2 = 0.7636
11,500
12,000
12,500
13,000
13,500
14,000
14,500
15,000
15,500
1999 2000 2001 2002 2003
Year
Freq
uenc
y
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Proportion of Trauma Cases by ISS: 1999 to 2003
79.94 79.97 78.5 76.8 77.63
6.31 6.45 7.26 7.52 7.45
6.2 6.21 6.71 7.62 7.26
7.55 7.37 7.52 8.06 7.66
0%
20%
40%
60%
80%
100%
1999 2000 2001 2002 2003
Year
Rate
minor(0-9) moderate(10-15) severe(16-24) most severe(25+)
1818
1919
2020
TriageTriage
THCIC hospital discharge data from 1999-2003 THCIC hospital discharge data from 1999-2003 Trauma cases are defined by ICD-9 CodeTrauma cases are defined by ICD-9 Code ISS scores are derived using the ICDMAP-90 ISS scores are derived using the ICDMAP-90
software developed by MacKenziesoftware developed by MacKenzie Undertriage = ISS>=16 treated at non-designated Undertriage = ISS>=16 treated at non-designated
hospitalhospital Overtriage = ISS 1-9 treated at Level I hospitalOvertriage = ISS 1-9 treated at Level I hospital
Examination of the data indicate:Examination of the data indicate: Undertriage is improving and approaching standardUndertriage is improving and approaching standard Overtriage is stable but not reaching standardOvertriage is stable but not reaching standard
2121
2222
2323
ConclusionConclusion
Hospital diversion continues at a high levelHospital diversion continues at a high level ER saturation-caused diversion may be ER saturation-caused diversion may be
improving at Level I’simproving at Level I’s Mortality is rising for most severe casesMortality is rising for most severe cases
Related to high level of diversion, overtriage, Related to high level of diversion, overtriage, other system and/or other pre-hospital/hospital other system and/or other pre-hospital/hospital factors?factors?
Undertriage is fairly good but overtriage Undertriage is fairly good but overtriage may be a problemmay be a problem