1. History of Trauma System Development in California David Hoyt, MD, FACS Professor and Chairman Department of Surgery University of California, Irvine Orange, California

2. 18 th &19 th Century Health Care Delivery House calls No rapid treatments Kitchen table surgery

3. 18 th & 19 th Century Hospitals All admissions needed approval Patients were refused admission: Incurable Cancer Epilepsy Contagious Smallpox Could not pay Paupers sent to ‘almshouse’ Not ‘worthy of admission’ Conditions of immorality Prostitution/STDs Alcoholism Unwed mothers

4. Where Did Emergency Patients Go? The Receiving Hospital A hospital that would ‘receive’ all emergency patients Los Angeles City Receiving Hospital System Received ‘ambulance cases’ Transferred to County General or other Hospitals

5. Early Hospital Emergency Care ‘Emergency Room’ or ‘Accident Room’ Cared for people who “had no place else to go”

6. Admission log - Los Angeles City Receiving Hospital April - June 1908 7.3 patients/day

7. The Patients & Situations of 1908 Trauma Pedestrian vs. Streetcar Traumatic arrest Horses Bites, kicks “Horse fell on him” Bar fights Knifes, bottles, fists Automobiles? Minor cuts bruises Industrial injures Cuts, crush, amputation Burns - nitrate movie film

8. The Patients & Situations of 1908 Social problems: Child abuse “Hit by father with board” Spouse abuse “Beaten by husband” Suicide GSW head, chest Potassium permanganate

9. The Patients & Situations of 1908 Abortion “Refused to give doctor’s name” Addictions: Alcohol H.B.D. H.B.D.V.M. Opiates (morphine) Tx = Coffee (caffeine) into gastric tube

10. The Patients & Situations of 1908 Asthma Tx = Chloral Hydrate & Strychnine (stimulant) Cardiac arrest Tx = Adrenaline Sexuality issues: Gonorrhea “suppression of urine” “Injury to perineum” “Slipped on apple” “How injured: masturbation” “Treatment: Bedrest”

11. Early Hospital Emergency Care Hospital ‘Emergency rooms’ staffed by: Doctors without a practice Doctors working ‘overtime’ Emergency Medicine - 1971

12. Emergency Nursing “Triage” - emergency nursing

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

14. Ambulances & Emergency Transport Began in War Time Walt Disney served in WW I - France

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

16. Who Operated Most Ambulance Services? Adopted by Funeral Services Had a vehicle that could transport a body in a supine position Could gain goodwill in community

19. Who Operated Our Ambulances? Some Los Angeles area companies

20. Local California Dispatch 1969 Automobile club study 70 different ‘ambulance phone numbers’ servicing a 26 mile section of San Diego freeway

21. California’s Original Minimum Ambulance Training Requirements One crewman must have Red Cross Advanced first aid card Other attendant (within 15 days of employment); Enrolled in basic first aid class Complete advanced first aid class within 90 days.

22. Ambulance Documentation & Billing Most documentation related to costs/charges Taxi meters would assure accurate fees

23. Mass Casualty Incident - Pre-EMS August 1, 1966 University of Texas Austin Sniper - Charles Whitman fired from top of 27 story clock tower 15 killed 31 wounded Six funeral homes sent 13 ambulances

24. Documentation and Billing -1966 No victim names taken No charting No Funeral Home billed for ambulance transport That night the same funeral homes that sent ambulances transported the dead for their final services In hearses NOT ambulances

25. Trauma Magnitude of the Problem “The neglected epidemic” 1966 -“The neglected epidemic”

26. What Changed A pre-hospital curriculum Pre-hospital Care became a profession 1970-72

27. Emergency In 1972 the TV show Emergency debuted The Jack Webb creation

28. 1970-1980 Developing local Trauma Systems: Los Angeles EMS Orange EMS San Diego EMS Santa Clara EMS

29. 1980 Development of California’s State EMS Leadership State law added Division 2.5 of the Health & Safety Code Established the Emergency Medical Services Authority LEMSA Model Started

30. 1983 Trauma Systems added to the Health & Safety Code Allow, but not require, development of local trauma care systems System based upon a series of local, optional trauma care systems

31. 1986 Trauma care regulations established California Code of Regulations, Title 22, Division 9, Chapter 7 Trauma Care Systems Promulgated to provide minimum standards for local trauma systems & locally designated trauma centers

32. Trauma System A Public Private Partnership Scripp’s Memorial Scripp’s Mercy UCSD Medical Center Sharp Memorial County Health EMS Palomar Medical Center Children’s Hospital

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

35. Trauma Center Standards Trauma Center Designation standards Data collection Quality improvement protocols

36. San Diego County CNS & Non CNS- 1982 12/90 Preventable Deaths (Amherst Study) System--------------1984 1984 3/112 (3m) Preventable 1986 11/541 Preventable Current rate < 1%

37. Significant Accomplishments Paramedic Training Regional EMS systems 911 ATLS Trauma Care standards Verification National Trauma Data Bank Disease Management Model

38. The Infrastructure

39. Started 2005

40. The Evidence All measurement techniques: 8-10% mortality reduction

41. NSCOT The National Study on Costs and Outcomes of Trauma Center Care NSCOT 25% - Mortality Reduction <55

42. The LEMSA Model – A Story of Great Success

43. Why Not Everywhere

44. ▲ Level I & II ● Level III-V Trauma Centers in the United States – All Levels Plotted by Hospital ZIP Code Why not everywhere ? Challenges ???

45. Percent of ISS > 15 Adult Patients Treated at a Level I/II Center # Level I/II per Pop’n % of ISS>15 Treated at a Level I/II Florida 1.1 56% California 1.2 55% North Carolina 1.1 66% Maryland 1.3 78% Pennsylvania 2.0 63% New York 2.4 69% Illinois 4.9 77% Missing Patients

46. 1987 Assembly Office of Research described California’s trauma care system: Medical & financial emergency, pointing to financial losses experienced by trauma centers & a need to financially stabilize trauma care systems Some hospitals (particularly in Los Angeles) dropped trauma center designation, citing financial losses.

47. 1980’s-1990’s Closure or threatened closure of trauma centers in several areas of the state resulted in media attention & policy initiatives to increase state subsidies or develop alternative funding sources Physicians & hospitals indicated the root problem of emergency & trauma care issues was uncompensated care

48. System Finance

49. Threats to Trauma Care Main Reason All Reasons

50. Despite Legislative Support Trauma Systems Reauthorization Federal Agenda Inconsistent

51. 1980’s-1990’s Several legislative proposals to provide funding for trauma care surfaced – most failed

52. 1987 The Legislature enacted Chapter 1240, Statutes of 1987 Allowed counties to establish a Maddy Emergency Medical Services Fund (Maddy Fund) Compensate health care providers (hospitals and physicians) for emergency services for the uninsured & compensate medically indigent Ensure the population has continued access to emergency care.

53. August 1999 California Regulations were updated

54. 1999 EMSA Vision Implementation Project begun

55. 2001 AB 430 (Cardenas) established Chapter 171 Statutes created the Trauma Care Fund & a formula for distribution of funds to local EMS agencies for designated trauma centers

56. 2001 California Statewide Trauma Planning: Assessment & Future Direction begun

57. October 2003 Vision Implementation Project Final Report Acknowledged System Status Provided Standards & direction for California Statewide Trauma Planning: Assessment & Future Direction

58. Process Trauma Advisory Committee started to develop a statewide trauma system plan in concept

59. Problem California state law allows for, but does not require, development of local trauma systems

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

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

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

63. EMS Authority 2003-2006 Did Federal and ACS assessment of current state system Federal – Public Health Model ACS – Systems Consultation Process Published California Statewide Trauma Planning: Assessment & Future Direction

64. September 2006 Governor Schwarzenegger signed California Statewide Trauma Planning: Assessment & Future Direction

65. EMSA 2008 Draft Implementation Plan Leadership Data Funding Synthesis of Trauma Advisory Committee and EMS Authority

67. Regional Structural Development It is proposed the state be divided into trauma regions with responsibilities to include creating access for underserved areas, balancing resources, and leveraging academic resources.

68. Humboldt Siskiyou Modoc Lassen ShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Regional EMS Agencies Single County EMS Agencies Local EMS Agencies

69. California Disaster Regions Region I (Los Angeles EMS) Region II (Contra Costa EMS) Region III (Northern California EMS) Region VI (Inland Counties EMS) Region IV (San Joaquin EMS) Region V (Kern County EMS) Del Norte Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras

70. Mapping of Regions Three regions Four regions Five regions Six regions

71. Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Northern California Region North Coast EMS Agency NorCal EMS Agency Sierra-Sacramento EMS Agency Sacramento County EMS Agency ElDorado County EMS Agency Coastal Valleys EMS Agency Solano County EMS Agency Central Region Contra Costa County EMS Agency San Francisco County EMS Agency San Mateo County EMS Agency Alameda County EMS Agency Santa Clara County EMS Agency Santa Cruz County EMS Agency San Benito County EMS Agency Monterey County EMS Agency Marin County EMS Agency Inland Counties EMS Agency (partial) Central California EMS Agency San Joaquin County EMS Agency Mountain Valley EMS Agency Merced County EMS Agency Tuolumne County EMS Agency Southern Region San Luis Obispo County EMS Agency Kern County EMS Agency Santa Barbara County EMS Agency Ventura County EMS Agency Los Angeles County EMS Agency Orange County EMS Agency Riverside County EMS Agency San Diego County EMS Agency Imperial County EMS Agency Inland Counties EMS Agency (partial)

72. Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Northern California Region North Coast EMS Agency NorCal EMS Agency Sierra-Sacramento EMS Agency Sacramento County EMS Agency ElDorado County EMS Agency Coastal Valleys EMS Agency Solano County EMS Agency Marin County EMS Agency Central Region Contra Costa County EMS Agency San Francisco County EMS Agency San Mateo County EMS Agency Alameda County EMS Agency Santa Clara County EMS Agency Santa Cruz County EMS Agency San Benito County EMS Agency Monterey County EMS Agency Marin County EMS Agency Inland Counties EMS Agency (partial) Central California EMS Agency San Joaquin County EMS Agency Mountain Valley EMS Agency Merced County EMS Agency Tuolumne County EMS Agency Southern Region San Luis Obispo County EMS Agency Kern County EMS Agency Santa Barbara County EMS Agency Ventura County EMS Agency Los Angeles County EMS Agency Orange County EMS Agency Southeast Region Inland Counties EMS Agency (partial) Riverside County EMS Agency San Diego County EMS Agency Imperial County EMS Agency

73. Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Northern California Region North Coast EMS Agency NorCal EMS Agency Sierra-Sacramento EMS Agency Sacramento County EMS Agency ElDorado County EMS Agency Coastal Valleys EMS Agency Marin County EMS Agency Eastern California Region Inland Counties EMS Agency Riverside County EMS Agency San Diego County EMS Agency Imperial County EMS Agency Bay Area Region Solano County EMS Agency Contra Costa County EMS Agency San Francisco County EMS Agency San Mateo County EMS Agency Alameda County EMS Agency Santa Clara County EMS Agency Santa Cruz County EMS Agency San Benito County EMS Agency Monterey County EMS Agency Central California Region San Joaquin County EMS Agency Mountain Valley EMS Agency Merced County EMS Agency Central California EMS Agency Tuolumne County EMS Agency Southern Region San Luis Obispo County EMS Agency Kern County EMS Agency Santa Barbara County EMS Agency Ventura County EMS Agency Los Angeles County EMS Agency Orange County EMS Agency

74. Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Northern OES Region III NorCal EMS Agency Sierra-Sacramento EMS Agency (partial) Southern OES Region VI Inland Counties EMS Agency Riverside County EMS Agency San Diego County EMS Agency Imperial County EMS Agency Coastal OES Region II Solano County EMS Agency Contra Costa County EMS Agency San Francisco County EMS Agency San Mateo County EMS Agency Alameda County EMS Agency Santa Clara County EMS Agency Santa Cruz County EMS Agency San Benito County EMS Agency Monterey County EMS Agency North Coast EMS Agency Marin County EMS Agency Coastal Valleys EMS Agency Valley OES Region V Merced County EMS Agency Central California EMS Agency Kern County EMS Agency Southern OES Region I San Luis Obispo County EMS Agency Santa Barbara County EMS Agency Ventura County EMS Agency Los Angeles County EMS Agency Orange County EMS Agency Inland OES Region IV Mountain Valley EMS Agency ElDorado County EMS Agency Sierra-Sacramento EMS Agency (partial) Sacramento County EMS Agency San Joaquin County EMS Agency Tuolumne County EMS Agency

75. Del Norte California Trauma Centers

76. Humboldt Siskiyou Modoc LassenShastaTrinity Tehama Plumas Sierra Butte Glenn Nevada Placer Colusa Mendocino Lake Sonoma Napa Yolo Sutter Yuba El Dorado Amador Alpine Mono Tuolumne Sacramento San Joaquin Solano Contra Costa Marin San Francisco San Mateo Santa Cruz Alameda Santa Clara Stanislaus Merced Mariposa Madera San Benito Monterey Fresno Inyo Kings Tulare Kern San Luis Obispo Santa Barbara Ventura Los Angeles San Bernardino Riverside Orange San Diego Imperial Calaveras Del Norte Proposed Regional Committees

77. Region #1 Patient flow

78. Region #1

79. Region #2

80. Region #3 Central Region #3 Patient flow

81. Region #3

82. Region #4 Patient flow

83. Region #4

84. Region #5 Patient flow

85. Region #5

86. California State Trauma System Implementation 2. Develop Statewide Trauma Registry Data submission from local EMS agencies Generate information fo Future Policy Decisions Standard Data Definitions

87. California State Trauma System Implementation Data system Current grant to get started Data definitions complete Entry criteria complete

88. Funding A stable source of funding is needed A recent Harris poll suggests 90% of Americans are willing to pay for trauma resources Systematic review of funding options will be explored

89. Funding possibilities Local property tax License tax High risk behavior tax Vehicular insurance fees Local government ballot measures State ballot initiatives Supplemental payment (Medicare/MediCal match) Homeland Security funding State user surcharge fees User fees on arms and ammunition New construction fees Mitigation fees Broad provider involvement (pay or play) Individual citizen taxation

90. California State Trauma System Implementation Trauma System Local Assistance Funding Local administration Enhancements of trauma care Uncompensated care

91. Summary Much work has been done by the Trauma Advisory Committee and the EMSA A plan for state organizational structure, regional structural development, data systems, and funding has been developed This meeting is aimed at starting the implementation process

93. July Summit Regions for RTCCs defined Local Committees started Goals first year Create Regional committee governance Create template for quality improvement and data use Identify gaps in coverage and issues for region This is our landmark first meeting

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