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REGIONAL TRAUMA SYSTEMS:OPTIMAL ELEMENTS,INTEGRATION,AND ASSESSMENTSYSTEMS CONSULTATION GUIDE

COMMITTEE ON TRAUMA

AMERICAN COLLEGE OF SURGEONS

TRAUMA SYSTEM

EVALUATION AND PLANNING COMMITTEE


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Regional rauma Systems: Optimal Elements, Integration, and Assessment, American College of Surgeons Committeeon rauma: Systems Consultation Guideis intended as an instructive and evaluation tool to assist surgeons, healthcare institutions, and public health agencies in improving trauma systems and the care of injured patients. Itis not intended to replace the professional judgment of the surgeon or health care administrator in individualcircumstances. Te American College of Surgeons and its Committee on rauma cannot accept, and expresslydisclaim, liability for claims arising from the use of this work.

Copyright 2008 American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3211

All rights reserved.

ISBN 978-1-880696-33-0


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EDITOR IN CHIEF

Avery B. Nathens, MD, PhD, FACSCanada Research Chair in rauma SystemsDevelopmentDivision Head General Surgery and Director of raumaSt Michaels Hospitaloronto, ON

CONTRIBUTORS

In Alphabetical Order

Jane W. Ball, RN, DrPHrauma Systems ConsultantACS rauma Systems Evaluation and PlanningCommitteeGaithersburg, MD

Reginald A. Burton, MD, FACSrauma DirectorBryan LGH Medical CenterLincoln, NE

Sridhara Channarayapatn, MDMoss Rehab Hospital & Albert Einstein MedicalCenterElkins Park, PA

David L. Ciraulo, DO, FACS, MPHAssociate Professor Department of SurgerySurgical AssociatesPortland, ME

Arthur Cooper, MD, FACSProfessor of SurgeryDirector, rauma and Pediatric Surgical Services

Columbia University Affi liation at Harlem HospitalCenterNew York, NY

Gail F. Cooperrauma Systems ConsultantACS rauma Systems Evaluation and PlanningCommitteeEl Cajon, CA

A. Brent Eastman, MD, FACSChief Medical Offi cerN. Paul Whittier Chair of rauma, SMH LJScripps-HealthSan Diego, CA

MartinR. Eichelberger, MD, FACSProfessor of Pediatrics and Surgery

George Washington University School of MedicineDirector, rauma & Burn ServiceChildrens National Medical CenterWashington, DC

Tomas J. Esposito, MD, FACSChief, Section of raumaDepartment of SurgeryLoyola University Medical CenterMaywood, IL

Alberto Esquenazi, MDChair Department of Physical Medicine &Rehabilitation & Chief Medical Offi cer

Moss Rehab & Albert Einstein Medical CenterDirector Gait & Motion Analysis Laboratory andRegional Amputee CenterPhiladelphia, PA

Mary Sue Jones, RN, MSrauma System CoordinatorDelaware Health & Social Services, Division of PublicHealth, Offi ce of EMSDover, DE

Christoph Robert Kaufmann, MD, FACSAssociate Medical Director, rauma ServiceLegacy Emanuel HospitalPortland, OR

Jon R. Krohmer, MD, FACEPDeputy Chief Medical Offi cerUS Department of Homeland SecurityWashington, DC

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Editor & Contributors iii


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iv Regional rauma Systems: Optimal Elements, Integration, and Assessment

Linda Laskowski-Jones, RN, MS, APRN, BC,CCRN, CENVice President, Emergency, rauma & AeromedicalServicesChristiana Care Health SystemNewark, DE

Robert C. Mackersie, MD, FACSProfessor of Surgery in ResidenceSan Francisco General HospitalSan Francisco, CA

N. Clay Mann, PhD, MSAssociate Director for ResearchIntermountain Injury Control Research CenterUniversity of Utah School of MedicineSalt Lake City, U

J. Wayne Meredith, MD, FACSMedical Director, ACS rauma Programs

Richard . Myers Professor and Chair, Department ofGeneral SurgeryDivision of Surgical SciencesWake Forest University School of MedicineWinston-Salem, NC

Holly MichaelsProgram Coordinator, rauma Systems ConsultationAmerican College of Surgeons

Richard Mullins, MD, FACSProfessor of SurgeryDirector, rauma ServiceOregon Health & Science University

Portland, OR

Avery B. Nathens, MD, PhD, FACSCanada Research Chair in rauma Systems DevelopmentDivision Head General Surgery & Director of raumaSt Michaels Hospitaloronto, ON

Michael F. Rotondo, MD, FACSChair, ACS rauma Systems Evaluation and PlanningCommitteeProfessor of Surgery and Vice Chairman for ClinicalAffairsChief, rauma & Surgical Critical CareEast Carolina University School of MedicineGreenville, NC

Nels D. Sanddal, MS, REM-BPresidentCritical Illness and rauma Foundationrauma Systems ConsultantACS rauma Systems Evaluation and PlanningCommittee

Bozeman, M

Heather A. SoucyProgram Support SpecialistRural EMS & rauma echnical Assistance CenterBozeman, M

Shelly D. immons, MD, PhD, FACSChief of Neurotrauma DivisionDepartment of NeurosurgeryUniversity of ennessee Health Science CenterMemphis, N

Jolene R. Whitney, MPA

Assistant DirectorBureau of Emergency Medical ServicesUtah Department of HealthSalt Lake City, U

Michelle WielgoszProgram Coordinator, rauma Systems ConsultationAmerican College of Surgeons

Carol WilliamsManager, rauma DepartmentAmerican College of Surgeons

Robert J. Winchell, MD, FACS

Head, Division of rauma and Burn SurgeryMaine Medical CenterPortland, ME


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Contributors............................................................................................................................................ iii

Preamble ..................................................................................................................................................vii

Section 1: Trauma System Assessment

Injury Epidemiology .......................................................................................................................... 1Indicators as a ool for System Assessment ........................................................................................ 2

Section 2: Trauma System Policy Development

Statutory Authority and Administrative Rules ................................................................................... 5

System Leadership ............................................................................................................................. 6

Coalition Building and Community Support .................................................................................... 7

Lead Agency and Human Resources Within the Lead Agency ........................................................... 8

rauma System Plan .......................................................................................................................... 9System Integration........................................................................................................................... 10

Financing ........................................................................................................................................ 11

Section 3: Trauma System Assurance

Prevention and Outreach ................................................................................................................. 13

Emergency Medical Services ............................................................................................................ 14

Definitive Care Facilities .................................................................................................................. 17

System Coordination and Patient Flow ............................................................................................ 20Rehabilitation .................................................................................................................................. 22

Disaster Preparedness....................................................................................................................... 23

System-wide Evaluation and Quality Assurance ............................................................................... 24

rauma Management Information Systems ..................................................................................... 26

Research .......................................................................................................................................... 27

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able of Contents v


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vi Regional rauma Systems: Optimal Elements, Integration, and Assessment

Section 4: Postconsultation Measures

Postconsultation Measures ............................................................................................................... 31

Assessment ...................................................................................................................................... 31

Policy Development ........................................................................................................................ 32

Assurance ........................................................................................................................................ 34

Suggested Reading .............................................................................................................................. 37

Appendix A: Glossary of Terms, Acronyms, and Abbreviations............................................... 43

Appendix B: Prereview Questionnaire (PRQ)................................................................................ 49


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Preamble vii

Te earliest organized systems of trauma care had 2components: (1) a concentration of care at centersdedicated to the care of injured patients; and (2)prehospital bypass such that severely injured patientswere transported not to the closest facility, but totrauma centers. Te focus on transport and definitivecare facilities, although relatively simple, was associatedwith a significant reduction in preventable deathsand injury-related mortality within the region served.Tese systems typically served population-dense urbancenters such that the designation of relatively few LevelI or II centers was suffi cient to address local needs.With an increasing recognition of the burden of injuryassociated with trauma outside of major metropolitanareas, including suburban and rural environments,it became evident that this exclusive approach totrauma center designation was inadequate. o betterserve the needs of the entire population, systems withan inclusive configuration were implemented. Tesesystems, in which all acute care facilities participate to

the extent that their resources allow, served 2 purposes:(1) Tey provided all centers with a means to assess andstabilize the conditions of patients before transport toLevel I or II centers if indicated. (2) Tey allowed forless severely injured patients to be cared for within theircommunity. Recent evidence suggests that inclusivesystems of trauma care are associated with a reductionin injury-related mortality within a region comparedwith exclusive systems.

Organized systems of trauma care are more thandefinitive care facilities and a means to transportpatients. Te system must be grounded in legislation,with policies and procedures to ensure that the systemcontinues to meets regional needs. Tus, there mustbe a means to ensure adequate funds and personnelto support systems operations, continuing qualityimprovement, and injury surveillance to identifyemergent new threats. As the trauma systems rolein reducing mortality and reintegrating the injuredback into society was increasingly understood, thetrauma systems expanded role in postacute care andrehabilitation was recognized.

History of the American Collegeof Surgeons Trauma SystemConsultation Process

Historically, in the United States, care of injuredpatients focused on trauma centers, not traumasystems. Tis focus stemmed from the existence oflarge county hospitals, which became de facto traumacenters. Dedicated trauma centers, beyond these countyhospitals, were developed beginning in 1966. Terewas also the sporadic development of trauma systemsbeginning with the state of Illinois designating traumacenters (a system) in 1971 and Maryland creating thestatewide Shock rauma System in Baltimore. Otherregions followed, such as Orange County, California,and San Diego, California, in the early 1980s.

Te first document to establish resource and processstandards for trauma centerswas published in theBulletin of the American College of Surgeonsin 1976and titled Optimal Hospital Resources for Care of the

Seriously Injured. Tis document formed the basis forthe American College of Surgeons (ACS)-Committeeon rauma (CO) rauma Center VerificationProgram. It was during trauma center verification sitevisits that it became evident there was also great interestin having assistance in developing trauma systems.However, at that time, the ACS-CO did not have thenecessary tools or processes to provide this service.

In 1992, under the auspices of the Health Resourcesand Services Administration (HRSA), the Modelrauma Care System Plan was developed for the UnitedStates. Te HRSA Model rauma plan was used as the

basis for the development of the ACS-CO raumaSystems Consultation Program in 1996, to meetthis national need. Te ACS-CO multidisciplinarycommittee established the following fundamentalprinciples for the rauma Systems ConsultationProgram:

rauma systems should be inclusive.

Tis program would be a consultation program asopposed to a verification program. It was thoughtthat the program should be designed to assist any

P


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viii Regional rauma Systems: Optimal Elements, Integration, and Assessment

region desirous of developing or improving analready existing a trauma system.

Te process and consultation team would bemultidisciplinary, reflecting the multidisciplinarynature of a trauma system.

Regions requesting a consultation visit would be ableto customize the consultation process. Customizationwas accomplished by allowing the requesting leadagency to submit specific questions and issues theregion wanted to be addressed. Te site visit teamcould thereby include people with the requisiteexpertise to serve the needs of the requesting agencyand participants.

All site visit work sessions would be inclusive and,thereby, include all participants who representedthe various components of the system (such assurgeons, nurses, hospital administrators, emergency

medical services agency, fire chiefs, and paramedicsand emergency medical technicians). Terefore, alldiscussions regarding the trauma system would takeplace with input from all key participants.

Te first consultation visit was conducted in Montanain 1999. During this initial consultation, the processwas tested and modified, including the use of anelectronic format for creating the consultation report.Numerous consultation site visits have been conductedand enabled refinements to the consultation process.

A Client Manual was developed to assist states andregions in preparing for the site visit. Tis document

was followed by the development of a Reviewer Manualto assist review team participants to assess the level oftrauma system maturity and to recommend operationalprocesses to move the system forward.

Te need for a more scientifically based assessmenttool grounded in the principles of public health wasidentified in 2002 by HRSA in cooperation with theACS-CO rauma Systems Committee. Te publichealth framework of assessment, policy development,and assurance, the guiding principles and corefunctions of public health, were also recognized as thebasis for developing trauma systems including injury

control and prevention programs. Tis need led to thedevelopment of theModel rauma System Planning andEvaluation (MSPE) document, released by HRSA in2006.

Based on this document and the recommendationfor regionalization by the 2006 Institute of Medicinereport (Te Future of Emergency Care in the US HealthCare System) and its experience in conducting traumasystem assessments, the ACS-CO concluded thata major update of the rauma Systems Consultation

Guidewas in order. Te Institute of Medicine reportspecifically acknowledged the ACS-CO raumaSystem Evaluation and Planning Committee efforts topromote regionalized, coordinated, and accountablesystems of care as a model for other emergency healthcare responses.

Public Health Model

Te events of September 11, 2001, led to a reviewof the emergency medical services and the publichealth infrastructure. What resulted was a broaderunderstanding of the need for emergency care andpublic health systems to work in a more collaborativeand cooperative environment. Tere came an awarenessof the need for prepared and fully interoperableemergency medical, trauma care, and all-hazardsresponse systems and the recognition of the importance

of the public health infrastructure in responding to allhazards, including terrorist activities. Add to this theclear parallels between the epidemiologic behaviorsof illness and injuries and the existing public healthstrategies used for communicable disease eradication,and it becomes evident that an organized system oftrauma care should interface very well with publichealth services. Tis interface is reflected in HRSAsMSPE, released in February 2006.

Te application of the public health model to traumasystems is based on the concept that injury as a diseasecan be prevented or its negative impacts decreased, orboth, by primary, secondary, and/or tertiary preventionefforts. Tese actions are similar to actions taken toreduce morbidity and mortality of infectious diseases.It is well recognized that excellent clinical trauma careand effective injury prevention programs are necessaryto reduce death and disability due to injury. Tisgoal can be obtained through partnerships amongtrauma system managers, health care providers, andpublic health agencies such that all 3 phases of injuryprevention are addressed. Key objectives in reducingthe burden of injury and in making improvements inthe trauma care of persons with serious injury includeforging effective collaborations among trauma system

agencies, community health care facilities, and publichealth departments.

Te public health system provides a conceptualframework for trauma system development,management, and ongoing performance improvement.Te 3 core functions of public health services areassessment, policy development, and assurance.

Assessmentis the regular and systematic collectionand analysis of data from a variety of sources to


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Preamble ix

determine the status and cause of a problem and toidentify potential opportunities for interventions.

Policy developmentuses the results of the assessmentin an organized manner to establish comprehensivepolicies intended to improve the publics health.

Assurance, agreed-on goals to improve the publicshealth, is achieved by providing services directly,by requiring services through regulation, or byencouraging the actions of others (public or private).

Te core functions of the public health approach asthey relate to trauma systems are demonstrated inFigure 1. Te relationship between these core functionsand trauma system components as described in HRSAsModel rauma Care System Componentsdocument

(1992) is illustrated in able 1. Te public healthcommunity moved to make core function conceptsmore clear by describing 10 essential services that arekey to providing public health at a local level. Teseessential services of public health are as follows:

1. Monitor health status to identify communityhealth problems.

2. Diagnose and investigate health problems andhealth hazards in the community.

3. Inform, educate, and empower people about healthissues.

4. Mobilize community partnerships to identify andsolve health problems.

From Health Resources and Services Administration.Modelrauma System Planning and Evaluation. Rockville, MD: HealthResources and Services Administration; 2006:18.

*Note that research, one of the 10 essential services, is key and is placed in the center, as it is research that drives the system.

Figure 1. Core functions and essential services of the trauma system integrated with public health.


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x Regional rauma Systems: Optimal Elements, Integration, and Assessment

5. Develop policies and plans that support individualand community health efforts.

6. Enforce laws and regulations that protect healthand ensure safety.

7. Link people to needed personal health services, andensure the provision of health care when otherwiseunavailable.

8. Ensure a competent public health and personalhealth care workforce.

9. Evaluate effectiveness, accessibility, and quality ofpersonal and population-based health services.

10. Conduct research to attain new insights andinnovative solutions to health problems.

Integration of the Trauma SystemsConsultation Guide With theHRSAs MTSPE Document

Te MSPEdocument offers a conceptual framework

for trauma system design and implementation. Tistrauma system consultation guide serves the purposeof assisting in the trauma system consultation process,irrespective of its phase of development or scope. Tisdocument thus serves to take the MSPE conceptualframework and convert it into an assessment tool tobe used at the time of trauma system consultation.Te MSPE contains a self-assessment tool for traumasystem planning, development, and evaluation. Tistool, referred to as the BIS (benchmarks, indicators,

Table 1. Comparison of Public Health Core Functions and 1992 Model Trauma Care System Components*

Public Health Core Functions Trauma System Components

Core Function Essential Service 1992 Core Components Subcomponents

Assessment Monitor healthDiagnose and investigate Evaluation Needs assessmentData collectionResearch

Policy Development Inform, educate, andempowerMobilize communitypartnerships

Public informationand education

Injury preventionrauma advisory committee

Develop policies Legislation andregulations

rauma system planning andoperationsRegulations and rules

Assurance Enforce laws Lead agency

Ensure links to or provisionof care

Prehospital care Communicationsriage and transport, medicaldirection, and treatmentprotocols

Definitive care Facilities (designation),interfacility transfer, andrehabilitation

Ensure competent workforce Human resources Workforce resources andeducational preparation

Evaluation Evaluation Data collection

ResearchInterdisciplinary reviewcommittee

Research

*From Health Resources and Services Administration.Modelrauma System Planning and Evaluation. Rockville, MD: HealthResources and Services Administration; 2006:16.


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Preamble xi

and scoring), serves to allow individuals within thesystem to identify gaps in their system and monitortheir progress over time. Te components of the BISare as follows:

Benchmarksare global overarching goals, expectations,

or outcomes. In the context of the trauma system, abenchmark identifies a broad system attribute.

Indicatorsare tasks or outputs that characterize thebenchmark. Indicators identify actions or capacitieswithin the benchmark and are the measurablecomponents of a benchmark.

Scoringbreaks down the indicator into completionsteps. Scoring provides an assessment of the currentstatus and marks progress over time toward reaching acertain milestone.

In development of the Regional rauma Systems:Optimal Elements, Integration, and Assessmentdocument, we strived to maintain consistency with theBIS and sought to identify benchmarks and indicatorsappropriate to the various trauma system components.Our broad objectives were to provide context andsubstance to the conceptual framework proposed inthe MSPE. Tis approach provides for a practicalapplication of the MSPE at the time of traumasystem consultation and allows stakeholders to readilytranslate assessments and recommendations providedat the time of consultation into the context of the

public health approach. o facilitate this translation,we have identified the benchmarks and indicatorsby their numbers (using the same numbers as in theHRSA document), preceded by a B (benchmark) or anI (indicator), in parentheses following system elements.In their simplest form, the indicators represent the

optimal elements of a system and are described as suchin their sections.

We attempted to ensure that the needs of thegeneralpopulation and special populationswould be met.Special populations include children; people who areelderly, disabled, and dispossessed (poor, homeless, andinstitutionalized); and tribal nations. We additionallytried to achieve a workable balance in the needs ofpatients, providers, payers, and the public.

Tis document is consistent with and supports theconcepts contained in the following:

Emergency Medical Services for Children Programperformance measures for state partnership grants

Centers for Disease Control and Prevention Fieldriage Guidelines

National Highway raffi c Safety Administrations Terauma System Agenda for the Future

Te introductions to the 4 sections of this doument arefrom the MSPE.


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rauma System Assessment 1

SECT ION 1

T S

A

ASSESSMENT

Regular systematic collection, assembly, analysis, anddissemination of information on the health of thecommunity

Injury Epidemiology

Purpose and Rationale

Injury epidemiology is concerned with the evaluationof the frequency, rates, and pattern of injury events ina population. Injury pattern refers to the occurrenceof injury-related events by time, place, and personalcharacteristics (for example, demographic factors suchas age, race, and sex) and behavior and environmentalexposures, and, thus, it provides a relatively simpleform of risk-factor assessment.

Te descriptive epidemiology of injury among thewhole jurisdictional population (geographic area

served) within a trauma system should be studied andreported. Injury epidemiology provides the data forpublic health action and becomes an important linkbetween injury prevention and control and traumasystem design and development. Within the traumasystem, injury epidemiology has an integral role indescribing the root causes of injury and identifyingpatterns of injury so that public health policy andprograms can be implemented. Knowledge of a regionsinjury epidemiology enables the identification ofpriorities for directing better allocation of resources, thenature and distribution of injury prevention activities,financing of the system, and health policy initiatives.

Te epidemiology of injury is obtained by analyzingdata from multiple sources. Tese sources mightinclude vital statistics, hospital administrative dischargedatabases, and data from emergency medical services(EMS), emergency departments (EDs), and traumaregistries. Motor-vehicle crash data might also proveuseful, as would data from the criminal justice systemfocusing on interpersonal conflict. It is important toassess the burden of injury across specific populationgroups (for example, children, elderly people, and

ethnic groups) to ensure that specific needs or riskfactors are identified. It is critical to assess ratesof injury appropriately and, thus, to identify theappropriate denominator (for example, admissionsper 100,000 population). Without such a measure, itbecomes diffi cult to provide valid comparisons acrossgeographic regions and over time.

o establish injury policy and develop an injuryprevention and control plan, the trauma system, inconjunction with the state or regional epidemiologist,should complete a risk assessment and gap analysisusing all available data. Tese data allow for anassessment of the injury health of the population(community, state, or region) and will allow for theassessment of whether injury prevention programs areavailable, accessible, effective, and effi cient.

An ongoing part of injury epidemiology is publichealth surveillance. In the case of injury surveillance,the trauma system provides routine and systematic

data collection and, along with its partners in publichealth, uses the data to complete injury analysis,interpretation, and dissemination of the injuryinformation. Public health offi cials and trauma leadersshould use injury surveillance data to describe andmonitor injury events and emerging injury trendsin their jurisdictions; to identify emerging threatsthat will call for a reassessment of priorities and/orreallocation of resources; and to assist in the planning,implementation, and evaluation of public healthinterventions and programs.

Optimal Elements*

I. Tere is a thorough description of theepidemiology of injury in the system jurisdictionusing population-based data and clinical databases.(B-101)

a. Tere is a through description of theepidemiology of injury mortality in the system

* Tis section adapted from Health Resources and Services Administration.Model Trauma System Planning and Evaluation. Rockville, MD: HealthResources and Services Administration; 2006.


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2 Regional rauma Systems: Optimal Elements, Integration, and Assessment

jurisdiction using population-based data.(I-101.1)

b. Tere is a description of injuries withinthe trauma system jurisdiction, includingthe distribution by geographic area, high-

risk populations (pediatric, elderly, distinctcultural/ethnic, rural, and others), incidence,prevalence, mechanism, manner, intent,mortality, contributing factors, determinants,morbidity, injury severity (including death),and patient distribution using any or all thefollowing: vital statistics, ED data, EMS data,hospital discharge data, state police data (datafrom law enforcement agencies), medicalexaminer data, trauma registry, and other datasources. Te description is updated at regularintervals. (I-101.2)

c. Tere is comparison of injury mortality usinglocal, regional, statewide, and national data.(I-101.3)

d. Collaboration exists among EMS, public healthoffi cials, and trauma system leaders to completeinjury risk assessments. (I-101.4)

e. Te trauma system works with EMS andpublic health agencies to identify special at-riskpopulations. (I-101.7)

II. Collected data are used to evaluate systemperformance and to develop public policy. (B-205)

a. Injury prevention programs use traumamanagement information system data todevelop intervention strategies. (I-205.4)

III. Te trauma, public health, and emergencypreparedness systems are closely linked. (B-208)

a. Te trauma system and the public healthsystem have established linkages, includingprograms with an emphasis on population-based public health surveillance and evaluationfor acute and chronic traumatic injury andinjury prevention. (I-208.1)

IV. Te jurisdictional lead agency, in cooperation withthe other agencies and organizations, uses analytictools to monitor the performance of population-based prevention and trauma care services. (B-304)

a. Te lead agency, along with partnerorganizations, prepares annual reports on thestatus on injury prevention and trauma care inthe state, regional, or local areas. (I-304.1)

b. Te trauma system management informationsystem database is available for routine public

health surveillance. Tere is concurrentaccess to the databases (ED, trauma,prehospital, medical examiner, and publichealth epidemiology) for the purpose ofroutine surveillance and monitoring of healthstatus that occurs regularly and is a shared

responsibility. (I-304.2)

Prereview Questionnaire

1. Describe the epidemiology of injury in your regionand unique features of:

a. Children

b. Adolescents

c. Elderly people

d. Other special populations

2. Describe the databases that are used to formulate

the injury epidemiology profile (for example,population-based and clinical).

3. Have system epidemiology profile results(for example, mortality rates, distributionof mechanism, or intent) been comparedwith benchmark values? If so, please providecomparisons and origins of the benchmarks.

4. Describe how emerging injury control patterns(for example, from trend or surveillance data) wereidentified and acted on.

5. Describe how ongoing and routine injury

surveillance is completed and how results areshared with constituent groups.

Documentation Required

Before the site visit:

No additional documentation required

On-site:

A copy of the most recent State and erritorialInjury Prevention Directors Association assessmentreport

Copy of the injury epidemiology report or profile

Indicators as a Toolfor System Assessment


In the absence of validated national benchmarks, ornorms, the benchmarks, indicators and scoring (BIS)process included in the Health Resources and ServicesAdministrationsModel Trauma System Planning and


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rauma System Assessment 3

Evaluation document provides a tool for each traumasystem to define its system-specific health statusbenchmarks and performance indicators and to usea variety of community health and public healthinterventions to improve the communitys health status.Te tool also addresses reducing the burden of injury as

a community-wide public health problem, not strictlyas a trauma patient care issue.

Tis BIS tool provides the instrument and process for arelatively objective state and substate (regional) traumasystem self-assessment. Te BIS process allows for theuse of state, regional, and local data and assets to driveconsensus responses to the BIS. It is essential thatthe BIS process be completed by a multidisciplinarystakeholder group, most often the equivalent of a statetrauma advisory committee. Te BIS process can helpfocus the discussion on various system strengths andweaknesses, can be used to set goals or benchmarks,

and provides the opportunity to target often limitedresources and energies to the areas identified as mostcritical during the consensus process. Te BIS processis useful to develop a snapshot of any given systemat a moment in time. However, its true usefulness isin repeated assessments that reveal progress towardachieving various benchmarks identified in the previousapplication of the BIS. Tis process further permitsthe trauma system to refine goals to be attained beforefuture reassessments using the tool.

Optimal Element*

I. Assurance to constituents that services necessaryto achieve agreed-on goals are provided byencouraging actions of others (public or private),requiring action through regulation, or providingservices directly. (B-300)


1. Has a multidisciplinary stakeholder groupparticipated in the scoring and consensus processassociated with the BIS tool? If not, are there plansto do so?

2. If the process has been completed, how were thefindings used?

3. Is there a date (year/month) set for a reassessmentusing the BIS tool to mark progress toward agreed-on goals or benchmarks?


Before the site visit:


On-site:

Copies of recommendations or actions emanatingfrom the BIS process

Notes or minutes from any multidisciplinarystakeholder group that applied the BIS

* Tis section adapted from Health Resources and Services Administration.ModelTrauma System Planning and Evaluation. Rockville, MD: HealthResources and Services Administration; 2006.


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rauma System Policy Development 5

POLICY DEVELOPMENT

Promoting the use of scientific knowledge in decisionmaking, which includes:

building constituencies,

identifying needs and setting priorities,

usinglegislative authority and funding to develop plans

and policies to address needs, and

ensuring the publics health and safety.

Statutory Authority andAdministrative Rules


Reducing morbidity and mortality due to injury isthe measure of success of a trauma system. A keyelement to this success is having the legal authority

necessary to improve and enhance care of injuredpeople through comprehensive legislation and throughimplementing regulations and administrative code,including the ability to regularly update laws, policies,procedures, and protocols. In the context of the traumasystem, comprehensive legislation means the statutes,regulations, or administrative codes necessary to meetor exceed a predescribed set of standards of care. Italso refers to the operating procedures necessary tocontinually improve the care of injured patients frominjury prevention and control programs throughpostinjury rehabilitation. Te ability to enforce lawsand rules guides the care and treatment of injured

patients throughout the continuum of care.Tere must be suffi cient legal authority to establish alead trauma agency and to plan, develop, maintain,and evaluate the trauma system during all phases ofcare. In addition, it is essential that as the developmentof the trauma system progresses, included in thelegislative mandate are provisions for collaboration,coordination, and integration with other entities alsoengaged in providing care, treatment, or surveillanceactivities related to injured people. A broad approach

to policy development should include the building ofsystem infrastructure that can ensure system oversightand future development, enforcement, and routinemonitoring of system performance; the updating oflaws, regulations or rules, and policies and procedures;and the establishment of best practices across allphases of intervention. Te success of the system inreducing morbidity and mortality due to traumaticinjury improves when all service providers and systemparticipants consistently comply with the rules, havethe ability to evaluate performance in a confidentialmanner, and work together to improve and enhance thetrauma system through defined policies.

Optimal Elements*

I. Comprehensive state statutory authority andadministrative rules support trauma system leadersand maintain trauma system infrastructure,planning, oversight, and future development.(B-201)

Te legislative authority states that all thetrauma system components, emergency medicalservices (EMS), injury control, incidentmanagement, and planning documents worktogether for the effective implementation ofthe trauma system (infrastructure is in place).(I-201.2)

Administrative rules and regulations directthe development of operational policies andprocedures at the state, regional, and locallevels. (I-201.3)

II. Te lead agency acts to protect the public welfareby enforcing various laws, rules, and regulations asthey pertain to the trauma system. (B-311)

Laws, rules, and regulations are routinelyreviewed and revised to continually strengthenand improve the trauma system. (I-311.4)


a.

b.

a.

SECT ION 2

T S

P D


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1. Describe how the current statutes and regulationsallow the state or region to:

develop, plan, and implement the traumasystem,

monitor and enforce rules,

designate the lead agency,

collect and protect confidential data, and

protect confidentiality of the qualityimprovement process.

2. Describe the process by which trauma systempolicies and procedures are developed or updatedto manage the system including:

the adoption of standards of care,

designation or verification of trauma centers,direct patient flow on the basis of designation,

data collection, and

system evaluation.

3. Within the context of statutes and regulation,describe how injury prevention, EMS, publichealth, the needs of special populations, andemergency management are integrated orcoordinated within the trauma system.


Before site visit: rauma system statutes and regulations

EMS statutes and regulations

On-site:

rauma system policies, procedures, standards, orother regulatory guidelines

System Leadership


In addition to lead agency staff and consultants (forexample, trauma system medical director), there areother significant leadership roles essential to developingmature trauma systems. A broad constituency of traumaleaders includes trauma center medical directors andnurse coordinators, prehospital personnel, injuryprevention advocates, and others. Tis broad groupof trauma leaders works with the lead agency toinform and educate others about the trauma system,implements trauma prevention programs, and assists in

a.

b.

c.

d.

e.

a.

b.c.

d.

e.

trauma system evaluation and research to ensure thatthe right patient, right hospital, and right time goalsare met. Tere is a strong role for the trauma systemleadership in conveying trauma system messages,building communication pathways, building coalitions,and collaborating with relevant individuals and groups.

Te marketing communication component of traumasystem development and maintenance begins witha consensus-built public information and educationplan. Te plan should emphasize the need for closecollaboration between coalitions and constituencygroups and increased public awareness of trauma asa disease. Te plan should be part of the ongoingand regular assessment of the trauma system and beupdated as frequently as necessary to meet the changingenvironment of the trauma system.

When there are challenges to providing the optimalcare to trauma patients within the system, the

leadership needs to effect change to produce the desiredresults. Broad system improvements require the abilityto identify challenges and the resources and authorityto make changes to improve system performance.However, system evaluation is a shared responsibility.Although the leadership will have a key role in theacquisition and analysis of system performance data,the multidisciplinary trauma oversight committee willshare the responsibility of interpreting those data froma broad systems perspective to help determine theeffi ciency and effectiveness of the system in meetingits stated performance goals and benchmarks. Allstakeholders have the responsibility of identifying

opportunities for system improvement and bringingthem to the attention of the multidisciplinarycommittee or the lead agency. Often, subtle changesin system performance are noticed by clinical careproviders long before they become apparent throughmore formal evaluation processes.

Perhaps the biggest challenge facing the lead agency isto synergize the diversity, complexity, and uniquenessof individuals and organizations into a finely tunedsystem for prevention of injury and for the provision ofquality care for injured patients. o meet this challenge,leaders in all phases of trauma care must demonstrate a

strong desire to work together to improve care providedto injured victims.

Optimal Elements*

I. rauma system leaders (lead agency, traumacenter personnel, and other stakeholders) use aprocess to establish, maintain, and constantly



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evaluate and improve a comprehensive traumasystem in cooperation with medical, professional,governmental, and other citizen organizations.(B-202)

II. Collected data are used to evaluate system

performance and to develop public policy. (B-205)III. rauma system leaders, including a trauma-specific

statewide multidisciplinary, multiagency advisorycommittee, regularly review system performancereports. (B-206)

IV. Te lead agency informs and educates state,regional, and local constituencies and policymakers to foster collaboration and cooperation forsystem enhancement and injury control. (B-207)


1. How does the lead agency bring constituency

groups together to review and monitor the traumasystem throughout each phase of care?

2. Describe the composition, responsibilities,and activities of the multidisciplinary traumasystem advisory committee(s) and the workingrelationship(s) with the trauma lead agency andthe EMS lead agency, if they are different.

Identify pediatric representatives on themultidisciplinary trauma system advisorycommittee and any pediatric advisory groupsthat provide input into trauma systemdevelopment.

Describe the process of involving experts in,and advocates for, special populations and howthey help drive regional trauma system policy.

Describe how the multidisciplinary advisorycommittee is involved in trauma systemperformanceevaluation (for example, reviewof system performance reports).

3. Provide examples of how the lead agencyand trauma system leadership (for example,trauma centers, trauma medical director, nursecoordinator, trauma administrator, and other

stakeholders) inform and educate policy makers,elected offi cials, community groups, and othersabout the trauma system, its strengths, and itsimprovement opportunities.

4. Describe the process to build or expand effectivetrauma leadership within the trauma system (forexample, succession planning, leadership courses,and workshops), including the lead agency andtrauma centers.

a.

b.

c.

5. Describe the process by which lead agency staffwould identify changes in system performance.

6. Describe how the multidisciplinary advisorycommittee is involved in trauma systemperformanceevaluation.


Before site visit:

A comprehensive organizational chart thatidentifies the lead agency staff (including contractemployees) assigned to the trauma program (full-or part-time)

A copy of the most recent trauma systemaggregated performance improvement reportgenerated by the lead agency

Organizational chart that illustrates the systemoversight committee, its subcommittee, and itsrelationship to the lead agency

On-site:

Copies of curriculum vitae for the trauma systemleadership: state EMS director, trauma systemmanager, state medical director, and state traumadirector

A copy of minutes or meeting notes pertaining tothe identification, discussion, and resolution of atrauma system (rather than a trauma center) issue

Coalition Building andCommunity Support


Coalition building is a continuous process ofcultivating and maintaining relationships withconstituents (interested citizens) in a state or regionwho agree to collaborate on injury control and traumasystem development. Key constituents include healthprofessionals, trauma center administrators, prehospitalcare providers, health insurers and payers, data experts,consumers and advocates, policy makers, and media

representatives. Te coalition of key constituentscomprises the trauma systems stakeholders. Teinvolvement of these key constituents is important forthe following:

rauma system plan development

Regionalization: promoting collaboration rather thancompetition between trauma centers

System integration


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State policy development: authorizing legislation andregulations

Financing initiatives

Disaster preparedness

Te coalition should be effectively organized throughthe formation of multidisciplinary state and regionaladvisory groups to coordinate trauma system planningand implementation efforts. Constituents alsocommunicate with elected offi cials and policy leadersregarding the development and sustainability of thetrauma system. Information and education are neededby constituents to be effective partners in policydevelopment for trauma system planning. Regularcommunication about the status of the trauma systemhelps these key partners to recognize needs and progressmade with trauma system implementation.

One of the most effective ways to educate electedoffi cials and the public is through an organized publicinformation and education effort that may involvea media campaign about the burden of injury in thestate and the need for trauma system development.Information and education are important to reduce theincidence of injury in all age groups and to demonstratethe value of an effective trauma system when a seriousinjury occurs.

Optimal Element*

I. Te lead agency informs and educates state,regional, and local constituencies and policy

makers to foster collaboration and cooperation forsystem enhancement and injury control. (B-207)


1. What is the status of the trauma systems coalition(for example, What is the status of recruitingmembers and building a coalition? Is the coalitionstrong and active? Does the coalition need newenergy? Who is not currently involved but shouldbe a part of your coalition?)?

What is the role of the coalition members(constituents and stakeholders) in promotingtrauma system development?

What is the method and frequency forcommunicating with coalition members?

2. Describe how the trauma system leadershipmobilizes community partners to improve thetrauma system through effective communicationand collaboration.


a.

b.

How has the community been approached toidentify injury control concerns?

What key problems has the communityidentified?

How do stakeholders bring system challenges

or deficiencies to the attention of the leadagency?


Before site visit:

A list of organizations represented for traumasystem planning or injury control (for example,multidisciplinary state advisory committee,subcommittees, and other groups supportingtrauma system development)

On-site:

A list of all coalition members, and identifyorganizations representing special populations(for example, children and people who are elderly,need rehabilitation, or are disabled)

wo or three different types of communication toconstituencies or the trauma system coalition (forexample, notice of planning meetings, newsletter,activity report, coalition updates, or mediamessage)

Lead Agency and Human ResourcesWithin the Lead Agency


Each trauma system (state, regional, local, as defined instate statute) should have a lead agency with a strongprogram manager who is responsible for leading thetrauma system. Te lead agency, usually a governmentagency, should have the authority, responsibility,and resources to lead the planning, development,operations, and evaluation of the trauma systemthroughout the continuum of care. Te lead agency,empowered through legislation, ensures system integrity

and provides for program integration with otherhealth care and community-based entities, namely,public health, EMS, disaster preparedness, emergencymanagement, law enforcement, social services, andother community-based organizations.

Te lead agency works through a variety of groupsto accomplish the goals of trauma system planning,implementation, and evaluation. Te ability to bringmultidisciplinary, multiagency advisory groups togetherto accomplish trauma system goals is essential in

a.

b.

c.


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developing and maintaining the trauma system and ispart of providing leadership to evolving and maturesystems.

Te lead agencys trauma system program managercoordinates trauma system design, the adoption of

minimum standards (prehospital and in-hospital),and provides for overall system evaluation throughperformance indicator assessment and assurance. Inaddition to a trauma program manager, the lead agencymust be suffi ciently staffed to actively participatein each phase of development and in maintainingthe system through a clearly defined structure fordecision making (policies and procedures) and throughproactive surveillance and evaluation.Minimumstaffi ng usually consists of a trauma system programmanager, data entry and analysis personnel, andmonitoring and compliance personnel. Additional staffresources include administrative support and a part-

time commitment from the public health epidemiologyservice to provide system evaluation and researchsupport.

Within the leadership and governance structure ofthe trauma system, there is a role for strong physicianleadership. Tis role is usually fulfilled by a full- orpart-time trauma medical director within the leadagency.

Optimal Elements*

I. Comprehensive state statutory authority andadministrative rules support trauma system leaders

and maintain trauma system infrastructure,planning, oversight, and future development.(B-201)

Te legislative authority (statutes andregulations) plans, develops, implements,manages, and evaluates the trauma systemand its component parts, including theidentification of the lead agency and thedesignation of trauma facilities. (I-201.1)

Te lead agency has adopted clearly definedtrauma system standards (for example, facilitystandards, triage and transfer guidelines,

and data collection standards) and hassuffi cient legal authority to ensure and enforcecompliance. (I-201.4)

II. Suffi cient resources, including financial andinfrastructure-related, support system planning,implementation, and maintenance. (B-204)


a.

b.


1. Describe the number, position titles, andpercentage of full-time equivalency of all personnelwithin the lead agency or contract personnelwho have roles or responsibilities to the traumaprogram.

2. Identify other personnel resources that supportthe trauma program activities of the lead agency(for example, epidemiology support from otherunits within the health department, public healthinterns)

3. Describe the adequacy of personnel resourcesavailable to the lead agency to sustain traumaprogram assessment, policy development, andassurance activities.

Identify impediments or barriers that hindersystem development.


Before site visit:

A comprehensive organizational chart thatidentifies the position of the lead agency withinthe broader governmental authority (for example,health department)

A job description for the trauma program managerand the trauma medical director

On-site:


Trauma System Plan


Each trauma system, as defined in statute, shouldhave a clearly articulated trauma system planningprocess resulting in a written trauma system plan.Te plan should be built on a completed inventory oftrauma system resources identifying gaps in servicesor resources and the location of assets. It should alsoinclude an assessment of population demographics,topography, or other access enhancements (locationof hospital and prehospital resources) or barriers toaccess. It is important that the plan identify specialpopulations (for example, pediatric, elderly, in need ofburn care, ethnic groups, rural) within the geographicarea served and address the needs of those populationswithin the planning process. A needs assessment (orother method of identifying injury patterns, patientcare review/preventable death study) should also becompleted for initial trauma system planning and

a.


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updated periodically as needed to assess system changesover time.

Te trauma system plan is developed by the lead traumaagency based on the results of a needs assessment andother data resources available for review. It describes

the system design, integrated and inclusive, withadopted standards of care for prehospital and hospitalpersonnel and a process to regularly review the planover time. Te plan is built on input from traumaadvisory committees (or stakeholder groups) that assistin analyzing data, identifying resources, and developingsystem standards of care, including system policiesand procedures and overall system design. Ideally,although every stakeholder group may not be satisfiedwith the plan or system design, the plan, to the extentpossible, should be based on consensus of the advisorycommittees and stakeholder groups. Tese advisorygroups should be able to review the plan before final

adoption and approve the plan before it is submitted tothe lead agency with authority for plan approval.

Te trauma system plan is used to guide systemdevelopment, implementation, and management.Each component of the trauma system (for example,prehospital, hospital, communications, andtransportation) is clearly defined and an establishedservice level identified (baseline) with goals forenhancement (benchmark). Within the plan areincorporated other planning documents used to ensureintegration of similar services and build collaborationand cooperation with those services. Service plans for

emergency preparedness, EMS, injury prevention andcontrol, public health, social services, and mental healthare examples of services for which the trauma systemplan should include an interface between agencies andservices.

Optimal Element*

I. Te state lead agency has a comprehensivewritten trauma system plan based on nationalguidelines. Te plan integrates the traumasystem with EMS, public health, emergencypreparedness, and incident management. Tewritten trauma system plan is developed in

collaboration with community partners andstakeholders. (B-203)

Te trauma system plan clearly describes thesystem design (including the componentsnecessary to have an integrated and inclusivetrauma system) and is used to guide systemimplementation and management. For


a.

example, the plan includes references toregulatory standards and documents andincludes methods of data collection andanalysis. (I-203.4)


1. Describe the process for the development orrevision of the trauma system plan.

Include the role of advisory and stakeholdergroups in the process.

2. Is there ongoing assessment of trauma resourcesand asset allocation within the system?

3. Describe the process used to determine traumasystem standards and trauma system policies.

How are they reviewed and evaluated?

What standards and policies exist for special

populations, including rural and frontierregions?

How are specialized needs addressed, includingburns, spinal cord injury, traumatic braininjury, and reimplantation?


Before site visit:

Copy of the written trauma system plan

On-site:


System Integration


rauma system integration is essential for the daily careof injured people and includes such services as mentalhealth, social services, child protective services, andpublic safety. Te trauma system should use the publichealth approach to injury prevention to contribute toreducing the entire burden of injury in a state or region.Tis approach enables the trauma system to address

primary, secondary, and tertiary injury preventionthrough closer integration with community healthprograms and mobilizing community partnerships.Te partnerships also include mental health, socialservices, child protection, and public safety services.Collaboration with the public health community alsoprovides access to health data that can be used forsystem assessment, development of public policy, andinforming and educating the community.

a.

a.

b.

c.


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Integration with EMS is essential because thissystem is linked with the emergency response andcommunication infrastructure and transports severelyinjured patients to trauma centers. riage protocolsshould exist for treatment and patient deliverydecisions. Regulations and procedures should exist for

online and off-line medical direction. In the event of adisaster affecting local trauma centers, EMS would havea major role in evacuating patients from trauma centersto safety or to other facilities or to make beds availablefor patients in greater need.

Te trauma system is a significant state and regionalresource for the response to mass casualty incidents(MCIs). Te trauma system and its trauma centersare essential for the rapid mobilization of resourcesduring MCIs. Preplanning and integration of thetrauma system with related systems (public health,EMS, and emergency preparedness) are critical for

rapid mobilization when a disaster or MCI occurs.Te extensive impact of disasters and MCIs on thefunctioning of trauma centers and the EMS and publichealth systems within the affected region or state mustbe considered, and joint planning for optimal use of allresources must occur to enable a coordinated responseto an MCI. rauma system leaders need to be activelyinvolved in emergency management planning toensure that trauma centers are integrated into the local,regional, and state disaster response plans.

Optimal Elements*

I. Te state lead agency has a comprehensive written

trauma system plan based on national guidelines.Te plan integrates the trauma system with EMS,public health, emergency preparedness, andincident management. Te written trauma systemplan is developed in collaboration with communitypartners and stakeholders. (B-203)

Te trauma system plan has established clearlydefined methods of integrating the traumasystem plan with the EMS, emergency, andpublic health preparedness plans. (I-203.7)

II. Te trauma, public health, and emergencypreparedness systems are closely linked. (B-208)


1. What is the trauma systems collaborationand integration with EMS, public health, andemergency management and programs such as:

prevention programs,


a.

a.

mental health,

social services,

law enforcement,

child protective services, and

public safety (such as fire, lifeguard, mountainrescue, and ski patrol)?


Before site visit:


On-site:


FinancingPurpose and Rationale

rauma systems need suffi cient funding to plan,implement, and evaluate a statewide or regional systemof care. All components of the trauma system needfunding, including prehospital, acute care facilities,rehabilitation, and prevention programs. Lead agencytrauma system management requires adequate fundingfor daily operations and other important activitiessuch as advisory committee meetings, development ofregulations, data collection, performance improvement,and public awareness and education. Adequate funding

to support the operation of trauma centers and theirstate of readiness to care for seriously injured patientswithin the state or region is essential. Te financialhealth of the trauma system is essential for ensuring itsintegrity and its improvement over time.

Te trauma system lead agency needs a process forassessing its own financial health, as well as that ofthe trauma system. A trauma system budget shouldbe prepared, and costs should be reported by eachcomponent, if possible. Routine collection of financialdata from all participating health care facilities isencouraged to fully identify the costs and revenues of

the trauma system, including costs and revenuespertaining to patient care, administrative, and traumacenter operations. When possible, the lead agencyfinancial planning should integrate with the budgetsand costs of the EMS system and disaster, rehabilitation,and prevention programs to enable development of acomprehensive financial health report.

rauma system financial planning should be relatedto the trauma plan outcome measures (for example,patient outcome measures such as mortality rates,

b.

c.

d.

e.

f.


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length of stay, and quality-of-life indicators). Suchinformation may demonstrate the value added byhaving a trauma system in place.

Optimal Elements*

I. Suffi cient resources, including financial and

infrastructure-related, support system planning,implementation, and maintenance. (B-204)

Financial resources exist that support theplanning, implementation, and ongoingmanagement of the administrative and clinicalcare components of the trauma system. (I-204.2)

Designated funding for trauma systeminfrastructure support (lead agency) islegislatively appropriated. (I-204.3)

Operational budgets (system administrationand operations, facilities administration and

operations, and EMS administration andoperations) are aligned with the trauma systemplan and priorities. (I-204.4)

II. Te financial aspects of the trauma systemsare integrated into the overall performanceimprovement system to ensure ongoing fine-tuning and cost-effectiveness. (B-309)

Collection and reimbursement data aresubmitted by each agency or institution on atleast an annual basis. Common definitions existfor collection and reimbursement data and aresubmitted by each agency. (I-309.2)


1. How does the lead agency track and analyzeinternal trauma system finances?


a.

b.

c.

a.

How does the advisory committee participatein the financial review process?

How frequently are trauma system financialreports published?

Which financial data are reported (lead agency

data, health facility data, or both)?

2. What is the lead agencys budget for the traumasystem?

3. What is the source of funding available to supportthe development, operations, and managementof the trauma system (for example, general funds,dedicated funds)?

4. What financial incentives and disincentives existfor trauma center participation in the traumasystem?

Specifically include arrangements foruncompensated and undercompensated care.


Before site visit:

A copy of the lead agencys budgets, identifyingline items directly related to goals and objectives ofthe trauma plan

A recent trauma system financial report

On-site:

Letters and/or legislation that document financial

or in-kind commitment Notice of awards and abstracts (active grants)

a.

b.

c.

a.


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rauma System Assurance 13

ASSURANCE

Ensuring constituents that services necessary to achieveagreed-on goals are provided by:

encouraging the actions of others (public and private),

requiring action through regulation, or

providing services directly.

Prevention and Outreach


rauma systems must develop prevention strategiesthat help control injury as part of an integrated,coordinated, and inclusive trauma system. Telead agency and providers throughout the systemshould be working with business organizations,community groups, and the public to enact preventionprograms and prevention strategies that are based on

epidemiologic data gleaned from the system.

Efforts at prevention must be targeted for the intendedaudience, well defined, and structured, so that theimpact of prevention efforts is system-wide. Teimplementation of injury control and preventionrequires the same priority as other aspects of the traumasystem, including adequate staffi ng, partnering withthe community, and taking advantage of outreachopportunities. Many systems focus information,education, and prevention efforts directly to thegeneral public (for example, restraint use, drivingwhile intoxicated). However, a portion of these efforts

should be directed toward emergency medical services(EMS) and trauma care personnel safety (for example,securing the scene, infection control). Collaborationwith public service agencies, such as the departmentof health is essential to successful prevention programimplementation. Such partnerships can serve tosynergize and increase the effi ciency of individualefforts. Alliances with multiple agencies within thesystem, hospitals, and professional associations,working toward the formation of an injury controlnetwork, are beneficial.

Activities that are essential to the development andimplementation of injury control and preventionprograms include the following:

A needs assessment focusing on the publicinformation needed for media relations, publicoffi cials, general public, and third-party payers, thusensuring a better understanding of injury control and

prevention Needs assessment for the general medical community,

including physicians, nurses, prehospital careproviders, and others concerning trauma system andinjury control information

Preparation of annual reports on the status of injuryprevention and trauma care in the system

rauma system databases that are available and usablefor routine public health surveillance

Optimal Elements*

I. Te lead agency informs and educates state,regional, and local constituencies and policymakers to foster collaboration and cooperation forsystem enhancement and injury control. (B-207)

Te trauma system leaders (lead agency,advisory committees, and others) inform andeducate constituencies and policy makersthrough community development activities,targeted media messaging, and activecollaborations aimed at injury prevention andtrauma system development. (I-207.2)

II. Te jurisdictional lead agency, in cooperation with

other agencies and organizations, uses analytictools to monitor the performance of population-based prevention and trauma care services. (B-304)

Te lead agency, along with partnerorganizations, prepares annual reports on thestatus of injury prevention and trauma care instate, regional, or local areas (I-304.1)


a.

a.

SECTION 3

T S

A


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III. Te lead agency ensures that the trauma systemdemonstrates prevention and medical outreachactivities within its defined service area. (B-306)

Te trauma system is active within itsjurisdiction in the evaluation of community-

based activities and injury prevention andresponse programs. (I-306.2)

Te effect or impact of outreach programs(medical and community training and supportand prevention activities) is evaluated as partof a system performance improvement process.(I-306.3)


1. List organizations dedicated to injury preventionwithin the region and the issues they address (forexample, MADD, SADD, SafeKids Worldwide,Injury Free Coalition for Kids, American raumaSociety, university-based injury control programs).

2. Describe how the trauma lead agency has fundedand coordinated system-wide injury prevention oroutreach activities.

Which injuries (including pediatric injuries)have been identified and prioritized forintervention strategies?

Identify any dedicated lead agency or otheragency staff member (full- or part-time)responsible for injury prevention outreach andcoordination for the trauma system.

What is the source of funding?

3. Explain the evaluation process for injuryprevention projects that are conducted by the leadagency, trauma facilities, or other community-based organizations.

Identify any gaps in injury prevention effortsfor population groups in the state.


Before site visit:

A list of the number and nature of injuryprevention activities conducted throughout thetrauma system in the past year (for example,activities directed at which mechanism or typeof injury or which patient population, such aschildren and elderly people)

On-site:

A copy of the state injury control and preventionplan

a.

b.

a.

b.

c.

a.

A representative sample of brochures, pamphlets,fliers, and curricula for educational programs oninjury prevention

Emergency Medical ServicesPurpose and Rationale

Te trauma system includes, and/or interacts with,many different agencies, institutions, and systems. TeEMS system is one of the most important of theserelationships. EMS is often the critical link betweenthe injury-producing event and definitive care at atrauma center. Even though at its inception the EMSsystem was a very broad system concept, over time,EMS has come to be recognized as the prehospital carecomponent of the larger emergency health care system.It is a complex system that not only transports patients,

but also includes public access, communications,personnel, triage, data collection, and qualityimprovement activities.

Te EMS system medical director must have statutoryauthority to develop protocols, oversee practice, andestablish a means of ongoing quality assessment toensure the optimal provision of prehospital care. Ifnot the same individual, the EMS system medicaldirector must work closely with the trauma systemmedical director to ensure that protocols and goals aremutually aligned. Te EMS system medical directormust also have ongoing interaction with EMS agency

medical directors at local levels, as well as the stateEMS for Children program, to ensure that there isunderstanding of and compliance with trauma triageand destination protocols.

Ideally, a system should have some means of ensuringwhether resources meet the needs of the population.o achieve this end, a resource and needs assessmentevaluating the availability and geographic distributionof EMS personnel and physical resources is importantto ensure a rapid and appropriate response. Tisassessment includes a detailed description of thedistribution of ground ambulance and aeromedical

locations across the region. Resource allocationsmust be assessed on a periodic basis as needs dictatea redistribution of resources. In communities withfull-time paid EMS agencies, ambulances should bepositioned according to predictable geographic ortemporal demands to optimize response effi ciencies.Such positioning schemes require strong prehospitaldata collection systems that can track the location ofoccurrences over time. Periodic assessment of dispatchand transport times will also provide insight intowhether resources are consistent with needs.


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Each region should have objective criteria dictatingthe level of response (advanced life support [ALS],basic life support [BLS]), the mode of transport,and the disposition of the patient based on thelocation of the incident and the severity of injury. Amechanism for case-based review of trauma patients

that involves prehospital and hospital providers allowsbidirectional information sharing and continuingeducation, ensuring that expectations are met atboth ends. Ongoing review of triage and treatmentdecisions allows for continuing quality improvementof the triage and prehospital care protocols. A moredetailed discussion of in-field (primary) triage criteria isprovided in the section titled: System Coordination andPatient Flow (p 20).

Human Resources

Periodic workforce assessments of EMS should beconducted to ensure adequate numbers and distributionof personnel. EMS, not unlike other health careprofessions, experiences shortages and maldistributionof personnel. Some means of addressing recruitment,retention, and engagement of qualified personnelshould be a priority. It is critical that trauma systemleaders work to ensure that prehospital care providersat all levels attain and maintain competence in traumacare. Maintenance of competence should be ensured byrequiring standards for credentialing and certificationand specifying continuing educational requirements forall prehospital personnel involved in trauma care. Tecore curricula for First Responder, Emergency Medical

echnician (EM)-Basic, EM-Intermediate, EM-Paramedic, and other levels of prehospital personnelhave an essential orientation to trauma care for all ages.However, trauma care knowledge and skills need to becontinuously updated, refined, and expanded throughtargeted trauma care training such as Prehospitalrauma Life Support, Basic rauma Life Support,and age-specific courses. Mechanisms for the periodicassessment of competence, educational needs, andeducation availability within the system should beincorporated into the trauma system plan.

Systems of excellence also encourage EMS providersto go beyond meeting state standards for agencylicensure and to seek national accreditation. Nationalaccreditation standards exist for ground-based andair medical agencies, as well as for EMS educationalprograms. In some states, agency licensure requirementsare waived or substantially simplified if the EMS agencymaintains national accreditation.

EMS is the only component of the emergency healthcare and trauma system that depends on a large cadreof volunteers. In some states, substantially more thanhalf of all EMS agencies are staffed by volunteers. Tese

agencies typically serve rural areas and are essential tothe provision of immediate care to trauma patients,in addition to provision of effi cient transportationto the appropriate facility. In some smaller facilities,EMS personnel also become part of the emergencyresuscitation team, augmenting hospital personnel. Te

trauma care system program should reach out to thesevolunteer agencies to help them achieve their vital rolein the outcome of care of trauma patients. However, itmust be noted that there is a delicate balance betweenexpecting quality performance in these agencies andplacing unrealistic demands on their response capacity.In many cases, it is better to ensure that there is anoptimal BLS response available at all times ratherthan a sporadic or less timely response involving ALSpersonnel. Support to volunteer EMS systems may bein the form of quality improvement activities, training,clinical opportunities, and support to the systemmedical director.

Owing to the multidisciplinary nature of traumasystem response to injury, conferences that include alllevels of providers (for example, prehospital personnel,nurses, and physicians) need to occur regularly witheach level of personnel respected for its role in the careand outcome of trauma patients. Communication withand respect for prehospital providers is particularlyimportant, especially in rural areas where exposure tomajor trauma patients might be relatively rare.

Integration of EMS Within the Trauma System

In addition to its critical role in the prehospital

treatment and transportation of injured patients, EMSmust also be engaged in assessment and integrationfunctions that include the trauma system and alsopublic health and other public safety agencies. EMSagencies should have a critical role in ensuringthat communication systems are available andhave suffi cient redundancy so that trauma systemstakeholders will be able to assess and act to limitdeath and disability at the single patient level andat the population level in the case of mass casualtyincidents (MCIs). Enhanced 911 services and a centralcommunication system for the EMS/trauma system toensure field-to-facility bidirectional communications,interfacility dialogue, and all-hazards responsecommunications among all system participants areimportant for integrating a systems response. Wirelesscommunications capabilities, including automatic crashnotification, hold great promise for quickly identifyingtrauma-producing events, thereby reducing delays indiscovery and decreasing prehospital response intervals.

Further integration might be accomplished through theuse of EMS data to help define high-risk geographicand demographic characteristics of injuries within a


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response area. EMS should assist with the identificationof injury prevention program needs and in the deliveryof prevention messages. EMS also serves a critical rolein the development of all-hazards response plans and inthe implementation of those plans during a crisis. Tisintegration should be provided by the state and regional

trauma plan and overseen by the lead agency. EMSshould participate through its leadership in all aspectsof trauma system design, evaluation, and operation,including policy development, public education, andstrategic planning.

Optimal Elements*

I. Te trauma system is supported by an EMS systemthat includes communications, medical oversight,prehospital triage, and transportation; the traumasystem, EMS system, and public health agency arewell integrated. (B-302)

Tere is well-defined trauma system medicaloversight integrating the specialty needs of thetrauma system with the medical oversight forthe overall EMS system. (I-302.1)

Tere is a clearly defined, cooperative, andongoing relationship between the traumaspecialty physician leaders (for example, traumamedical director within each trauma center)and the EMS system medical director. (I-302.2)

Tere is clear-cut legal authority andresponsibility for the EMS system medicaldirector, including the authority to adopt

protocols, to implement a performanceimprovement system, to restrict the practiceof prehospital care providers, and to generallyensure medical appropriateness of the EMSsystem. (I-302.3)

Te trauma system medical director is activelyinvolved with the development, implementation,and ongoing evaluation of system dispatchprotocols to ensure they are congruent withthe trauma system design. Tese protocolsinclude, but are not limited to, which resourcesto dispatch, for example, ALS versus BLS, air-

ground coordination, early notification of thetrauma care facility, prearrival instructions,and other procedures necessary to ensure thatresources dispatched are consistent with theneeds of injured patients. (I-302.4)

Te retrospective medical oversight of the EMSsystem for trauma triage, communications,


a.

b.

c.

d.

e.

treatment, and transport is closely coordinatedwith the established performance improvementprocesses of the trauma system. (I-302.5)

Tere is a universal access number for citizensto access the EMS/trauma system, with

dispatch of appropriate medical resources.Tere is a central communication systemfor the EMS/trauma system to ensure field-to-facility bidirectional communications,interfacility dialogue, and all-hazards responsecommunications among all system participants.(I-302.7)

Tere are suffi cient and well-coordinatedtransportation resources to ensure that EMSproviders arrive at the scene promptly andexpeditiously transport the patient to thecorrect hospital by the correct transportationmode. (I-302.8)

II. Te lead trauma authority ensures a competentworkforce. (B-310)

In cooperation with the prehospital certificationand licensure authority, set guidelines forprehospital personnel for initial and ongoingtrauma training, including trauma-specificcourses and courses that are readily availablethroughout the state. (I-310.1)

In cooperation with the prehospitalcertification and licensure authority, ensure thatprehospital personnel who routinely provide

care to trauma patients have a current traumatraining certificate, for example, Prehospitalrauma Life Support or Basic raumaLife Support and others, or that traumatraining needs are driven by the performanceimprovement process. (I-310.2)

Conduct at least 1 multidisciplinary traumaconference annually that encourages system andteam approaches to trauma care. (I-310.9)

III. Te lead agency acts to protect the public welfareby enforcing various laws, rules, and regulations asthey pertain to the trauma system. (B-311)

Incentives are provided to individual agenciesand institutions to seek state or nationallyrecognized accreditation in areas that willcontribute to overall improvement across thetrauma system, for example, Commissionon Accreditation of Ambulance Services forprehospital agencies, Council on Allied HealthEducation Accreditation for training programs,and American College of Surgeons (ACS)verification for trauma facilities. (I-311.6)

f.

g.

a.

b.

c.

a.


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1. Provide information on the last assessment ofEMS, including assessor and date.

Describe the EMS system, including thenumber and competencies (that is, ALS

or BLS) of ground transporting agencies,nontransporting agencies, and air medicalresources.

How are these resources allocated throughoutthe region to serve the population?

Describe the availability of enhanced 911 andwireless E-911 access in your region.

Identify any specialty pediatric transportingagencies and aeromedical resources.

Describe the availability of pediatric equipmenton all ground transporting units.

2. Describe the procedures for online and off-linemedical direction, including procedures for thepediatric population.

Describe how EMS and trauma medicaldirection and oversight are coordinated

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