Area – 113,998 sq mi (6 th ) Population – 6.5 million (16th) Density 57/sq mi (33 rd ) Trivia 48 th State – 1912 The Grand Canyon State “Ditat Deus” Saguaro Blossom Palo Verde State Drink ??

 Long history of trauma system development  Seven historical high-level centers ◦ Located in urban areas ◦ Align with majority of population  Initial Trauma System consultation – 2007  Substantial increase in trauma centers  New challenges with center distribution  Perceived lack of strong central leadership  Stakeholder frustration  Substantial focus on Phoenix metro area

 Inclusive system by intent  Still an exclusive system in operational reality  Sufficient high-level trauma center resources ◦ 7 level I and II adult centers ◦ 1 level I pediatric center ◦ Some degree of maldistribution  Perception of oversupply in some areas  Clear undersupply in some areas  Well developed EMS, highly collaborative  No strong central control of trauma system ◦ Historical reliance on guidelines instead of rules

 Substantial funding ◦ State budget ◦ Proposition 202  Many areas of strength within BEMSTS ◦ Historical focus on EMS over trauma  Substantial progress since prior consultation  Historical challenges remain  New challenges have arisen

Progress since 2007

Definitive Care Facilities  All hospitals should be designated as trauma centers or participating hospitals as part of a statewide inclusive trauma care system.  Substantial progress has been made with the addition of 18 new trauma centers, most in underserved areas

Information Systems  The Arizona state trauma registry should expand its reach to include all acute care hospitals in the state.  Substantial progress. All designated trauma centers and an additional two non-designated facilities now contribute data

Leadership  Establish and fund a trauma medical director position to work under the guidance of the Bureau Chief.  Trauma medical director currently funded at 0.25 FTE

Research  Develop a statewide trauma research consortium, linked to the activities and functions of the STAB and AZTQ, for purposes of promoting research throughout the continuum of trauma care.  Partially implemented. NIH funded TBI study in progress, AZTrACC plan to coordinate multi- institutional research projects.

 Long history of strong participation ◦ Institutions ◦ Trauma leadership ◦ People  Substantial funding  ADHS and BEMSTS leadership committed  Sufficient number of high level centers  Rapid increase in rural level IV trauma centers  Growth of capacity outside urban areas  Fewer reported issues with diversion

 Sophisticated and collaborative EMS  Strong regulatory oversight of EMS  Adoption of CDC triage guidelines  Good trauma plan from 2005  Robust data infrastructure, including DQA  Collaborative research infrastructure  Diverse injury prevention programs  Disaster preparation at level of facilities

 Large remote land area, geographic isolation  Limited resources in rural areas  Potential maldistribution of trauma centers  Lead agency lacks (or perceives itself to lack) clear authority and mandate  Limited clinical trauma expertise in lead agency  Historical reliance on guidelines vs rules  Outdated advisory board structure  Lack of cohesive stakeholder involvement  Incomplete acceptance of inclusive system

 Mechanics of distribution of Prop 202 funds creates adverse incentives  Inability to designate centers based on need  Lack of clear destination protocols  Limited system-level integration with emergency preparedness efforts  Immature processes for system monitoring  Limited utilization of available data  Lack of clear constituency and legislative support

 There must be a clear vision and a clear plan for future direction, embraced by all stakeholders and by the bureau  Bureau needs to have clear support from stakeholders to lead, backed up by statutory and regulatory authority  Advisory committee need to be reconfigured to provide broader stakeholder participation and establish clear acceptance as balanced policy development group

 Trauma center designation should be based on need  Choice of destination from field or transfer should be consistent, and driven only by patient needs  Prop 202 funds not being used to their full potential ◦ No support for centers other than level 1 ◦ Distribution model fosters competition for volume  Sometimes you need rules  Remember you are all on the same team  The time to start is now

Focus Questions

 1a. - What evidence-based changes to our trauma system can you make to improve the delivery, efficiency and cost-effectiveness of trauma care to our citizens? ◦ Designate centers based on need and performance ◦ Develop and enforce specific destination standards ◦ Re-evaluate the way that Prop 202 funds are used Changes to Arizona Statutes and Rules

 1b. - Do you see a need for specific changes in our statutes and rules? If yes, what are they? ◦ Establish need as a pre-requisite for designation ◦ Establish destination protocols ◦ Determine a new distribution plan for Prop 202 funds Changes to Arizona Statutes and Rules

 2. - What recommendations can you make regarding how our statutory committees and regions currently provide clinical direction and oversight in regards to trauma care in our State? ◦ Restructure the advisory board to include all time- sensitive illnesses ◦ Ensure balanced representation from entire state ◦ Establish destination standards in rule ◦ Enhance role of regional councils Arizona Focus on Guideline vs Rule

 3. - What specific process and outcome metrics would you recommend to best measure the effectiveness of our state trauma system? ◦ A good preliminary list was provided in the 2007 report, including metrics regarding over and under triage, time to transfer, necessity for or failure to transfer, and deaths in non-trauma centers. ADHS Focus on Using Data to Enhance the System

 4. - What recommendations can you make to enhance the participation, evaluation and performance improvement of the rehabilitation community as a component of our system? ◦ Identify a funding source for rehab facilities ◦ Collect performance and outcome data from rehab facilities ◦ Actively collaborate to solve patient flow issues Rehabilitation Participation in the Trauma System

Statutory Authority and Administrative Rules  Amend trauma system statutes and rules to: ◦ Require a demonstration of need as a requirement for any provisional trauma center designation ◦ Establish standards of care relative to specific trauma destination protocols:  Establish a state template in rule based on CDC field triage criteria  Provide authority to the regions and require them to use the state template by rule to develop detailed destination procedures based on state template.

System Leadership  Encourage broader participation and more frequent turnover of committee membership  Regularly convene and empower a trauma program manager group to be a system advocate, contribute to trauma system development, inform the BEMSTS, and support TEPI in performance improvement efforts.

Lead Agency and Human Resources Within the Lead Agency  Establish a separate trauma medical director position (trauma surgeon) to provide the needed trauma system leadership and vision.

Trauma System Plan  Revise the Arizona trauma system plan in a broad based ad hoc subcommittee of the multidisciplinary trauma advisory committee. ◦ Ensure balanced rural and urban participation. ◦ Adopt the plan formally through a broad trauma stakeholders group, trauma advisory committee, and ADHS.  Perform a statewide needs assessment to evaluate optimal center placement prior to granting any new requests for provisional trauma center designation.

System Integration  Improve integration efforts between system leadership and Level III/IV trauma centers. ◦ Include level III and IV representation on advisory committee  Optimize the integration of STAB and the EMS Council ◦ Have more frequent meetings, and stagger the schedule to allow members with dual appointments to attend all meetings. ◦ Leverage electronic resources to facilitate meeting participation. ◦ Consider ad hoc workgroups to facilitate efforts. ◦ Increase trauma representation on EMS council.

Financing  Revise distribution method for Prop 202 funds to provide funding for all designated trauma centers in the system ◦ Change rule to ensure that all designated trauma centers receive level appropriate support for the “cost of readiness” ◦ Develop a formula for distribution of funds that focuses on specific deliverables by level rather than volume and acuity ◦ Include a mechanism to support trauma rehab services ◦ Revisit allocation method/ formula on a regular basis

Financing  Distribute funds through contractual agreement to ensure that each center continuously meets all of the requirements of verification/designation  Regularly monitor and audit fund distribution  Require hospitals to demonstrate that funds are used to support trauma service readiness and level- specific system participation

Definitive Care Facilities  Impose a moratorium on additional trauma center designation in Maricopa and Pima counties to allow for appropriate trauma system plan development.  Establish criteria and standards for designation and de-designation of trauma centers based upon need and performance.  Establish geographic catchment areas for individual high-level trauma centers to balance load, ensure effective outreach, minimize temporal maldistribution, and mitigate adverse effects of competition

System Coordination and Patient Flow  Establish regional destination standards and monitor compliance. ◦ Develop a state framework that can be adapted regionally. ◦ Clearly identify which facilities are appropriate to receive patients identified in each step of the field triage criteria.  Use BEMSTS’ statutory authority to mandate EMS services comply with accepted field triage destination standards.

Rehabilitation  Identify funding sources to facilitate the timely transfer of patients with uncompensated care to rehabilitation facilities.

System-wide Evaluation and Quality Assurance  Select the first audit filter from the provided list for review as part of TEPI’s trauma system performance improvement activities ◦ Schedule a meeting, and then start the review process.  Encourage the trauma system program manager to contact the NASEMSO trauma managers council for sample state trauma system PI plans. ◦ Use these resources to develop a state trauma system PI plan in collaboration with TEPI

Trauma Management Information Systems  Identify and convene a work group to develop reports assessing measurable objectives of trauma system performance ◦ Include metrics such as distribution of patients, transfer patterns, time to definitive care (field and transfer)  Assign TEPI to develop of a list of standardized reports to be run on a quarterly basis that will assist in ongoing monitoring of trauma system performance

Trauma Management Information Systems  Run and review the same list of reports for at least one full year before adaptation, deletion or substitution  Distribute the reports widely to stakeholders and advisory bodies.

Observations  This is a consultative process ◦ The recommendations offered are based on broad general principles and experiences in other regions ◦ The solutions will be unique and specific to Arizona  Change is always difficult  Progress will require an ongoing collaborative effort by all stakeholders  The solutions will be created by all of you  Audentes fortuna iuvat

Robert J. Winchell, MD, FACSTeam Leader Christopher C. Baker, MD, FACSTrauma Surgeon Jane Ball, RN, DrPHACS Consultant Rajan Gupta, MD, FACSTrauma Surgeon Heidi A. Hotz, RNTrauma Program Manager Janet Kastl, MA State EMS Director Nels D. Sanddal, PhD, REMT-B ACS Staff James D. Upchurch, MD Emergency Physician Carol Williams ACS Staff Closing Comments