EMS/Trauma Performance

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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

22

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

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


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


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


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


1313

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


1414

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


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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+)

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

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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

EMS/Trauma Performance

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