Seeking Legislative Change for Ohio’s Trauma System

1. Seeking Legislative Change for Ohio’s Trauma System

2. Why? • Growing understanding that current system has not resulted in hoped for improvement in outcomes and the widespread belief in the trauma community that we can do better • Well functioning trauma system should be able to show decreasing mortality rate by 10 years

5. Cost of Fatal Injuries, Both Sexes, All Ages, Ohio, 2005 CDC, WISQARS Database

6. Cost of Non-Fatal Injuries, Both Sexes, All Ages, Ohio, 2005 West Virginia University Injury Control Research Center

7. Problems with Current Legislation • EMS Board is the official Lead Trauma Agency for Ohio • Current law requires only verification of trauma centers by ACS • Current law does not allow the state to develop a system for designating trauma centers • Current law does not provide for personnel to manage the trauma system on a day to day basis • Current law requires that public reporting of trauma system outcomes be risk adjusted in all instances • Current application of state sunshine law does not allow for confidentiality of quality improvement activities • Current law does not address non-trauma centers’ role in trauma system

8. Why Now? • Interested Party meeting on merging EMS and Medical Transportation Boards • Trauma representatives objected to the proposal because of loss of what was already thought to be inadequate representation on the EMS Board to accomplish necessary changes in trauma system • An “Ah Ha” moment for the legislators and governor’s representative • Trauma had just been “stuck onto” EMS Board by prior legislation • Didn’t really fit EMS Board’s primary mission • Opinion corroborated by many of the other attendees • Hampered the improvement in the trauma system • Senator Widener requested that Drs. Jon Saxe and Steven Steinberg bring recommendations for new legislation to them

9. Process • Meeting Monday, February 18, 2013 in Columbus • Trauma experts from around state – including pediatric, nursing, and EMS representation • Utilized the last several years of work – Trauma Framework, NHTSA report, Tim Erskine’s (ODPS) Strategies and Indicators Document, etc. • Developed some idea for legislative change • ACS State Trauma System Consultation • Series of meetings with expanded group of trauma experts and Trauma Visionary Subcommittee (of Ohio Trauma Committee) • Discussions with key stakeholders – leadership of Division of EMS, leadership of ODH, OHA, legislators, governor’s representatives

10. Legislative Recommendations • Mandate ODPS to put out an RFP for a private foundation to manage the State of Ohio’s Trauma System and be the State’s Lead Trauma Agency • The Foundation will be governed by a Board, which will be responsible for all Foundation activities, including all of the below as well as hiring the key personnel detailed in the State Trauma System Administration slide • The Board will be the designating lead agency for trauma in the State of Ohio • Develop a system to designate hospitals as trauma centers • All trauma centers must undergo and pass the verification process of the American College of Surgeons Committee on Trauma • Clause D.1. will be voided if the Foundation ever develops its own verification process • Develop criteria and an application process for designation, re-designation, de-designation, voluntary withdrawal of trauma center status, re-activation of trauma center status, and an appeal process • These processes, except for the end result, will be confidential between the Foundation and individual hospital • The Board, at its discretion, may designate Level III Trauma Centers that meet the vast majority of ACS-COT verification requirements • Define how enforcement will be carried out

11. Legislative Recommendations • Develop a system to allow hospitals provisional trauma center status as they go through the designation process • The foundation will have rule making authority over the Trauma System (this may not be possible due to constitutional limitations) (rules for rule making) • Have a trauma system grant section to both administer grants, research and otherwise, as well as seek them • Develop a state-wide system for quality improvement • Develop a state-wide system for injury prevention • House and manage the state trauma and rehabilitation registries • A single patient identifier system will be developed • Provide trauma related education to health care providers in the pre-hospital and hospital settings to include both trauma and non-trauma centers

12. Other Legislated Functions • Require an annual public report on the status of the State’s Trauma System • The foundation will be allowed to charge and collect an annual fee from all hospitals and free standing emergency departments. A method of graduated charges will be developed. • Develop formal linkage to the regional trauma organizations • Develop minimum requirements to be recognized as a regional trauma organization • Develop budget for funding each qualified regional trauma organization • All hospitals and free standing emergency departments must participate in the foundation • The foundation will develop an INCLUSIVE trauma system to include all entities that care for trauma patients (Definition: An Inclusive Trauma System recognizes and has a place for all groups and institutions that play a role in trauma care or prevention including injury prevention specialists, pre-hospital care providers, trauma and non-trauma centers, and rehabilitation facilities) • Quality information and discussions protected • All meetings will be open but do not need to be in person • Committees and Board may go into executive session • Eliminate the current Ohio Trauma Committee of the EMS Board • Reduce trauma representation on EMS Board to 1

13. Board Composition • Trauma surgeon from each of the identified regions • At least one pediatric trauma surgeon • Trauma program manager from each of the identified regions of the state • At least on pediatric trauma program manager • Two hospital administrators from Level I or II trauma centers • Two hospital administrators from non-trauma centers • Two hospital administrators from a Level III trauma center • Representative of the Ohio Committee on Trauma • One rehabilitation physician • One orthopedic trauma surgeon • One neurosurgical trauma surgeon • One emergency medicine physician • A certified registrar • An injury prevention expert from ODH • A pre-hospital provider from the EMS Board • An at large lay person • A trauma victim advocate from the Governor’s Council on People with Disabilities

14. Requirements of the Board Members • Number of required meetings per year • Definition of who can become employed • Criteria for Board members: • Age • Resident status • Length of appointment • Filling vacancies • That they are Governor Appointments • Oath of Office • Per Diems; expenses and mileage • Election of Chair • Duties of Officers • Establish an office

15. State Trauma System Administration ACS Recommendation Positions * Current State-Funded Position State Trauma Board Trauma Executive Director (TPM) Trauma Medical Director Administrative Asst Trauma Regional Care Coordinator Accreditation Coordinator Injury Prevention Coordinator Grants Administration Coordinator Trauma Education Coordinator Performance Improvement Coordinator Trauma Registry Coordinator* EMSIRS Region A Coordinator Region A Medical Director Registrar* Regional B Medical Director Region B Coordinator Registrar* Region C Medical Director Region C Coordinator Region D Medical Director Region D Coordinator Region E Medical Director Region E Coordinator Epidemiologist* Biostatistician* Region F Medical Director Regional F Coordinator (number and geography of regions to be determined)

16. ACS Recommendation Positions * Current State-Funded Position ** Regional Medical Director/Regional Coordinator Team for each region as advised by the State Trauma Advisory Committee State Trauma Administration State Trauma Board Trauma Medical Director Provides overall medical program leadership in collaboration with the Trauma Systems Executive Director to establish, maintain and improve a comprehensive trauma system throughout the full trauma spectrum of care (injury prevention, prehospital , hospital and rehab services). Trauma System Executive Director (TPM) Provides overall program leadership in collaboration with the Trauma Medical Director to establish, maintain and improve a comprehensive trauma system including the full trauma spectrum from injury prevention, prehospital , hospital and rehabilitation services. Manages staff, operations, and budget to facilitate program performance. Trauma Registry Coordinator* Manages the state trauma and rehab registries. Accreditation Coordinator Responsible for the implementation, coordination, tracking and documentation of the hospital accreditation process in accordance with established standards, policies, and procedures. Trauma Regional Care Coordinator Develops formal linkage to the regional trauma organizations; develops minimum requirements for regional trauma organization; and develops budget for funding each qualified regional trauma organization. Provides the infrastructure for bidirectional communication between the state and regional trauma organizations to improve system-wide coordination of trauma care. Trauma Education Coordinator Develops, coordinates and provides oversight for trauma related education to healthcare providers in the pre-hospital and hospital settings to include both trauma and non-trauma hospitals. Grants Administration Coordinator Researches, identifies, writes and administers grants for funding, to support trauma system program activities. Injury Prevention Coordinator Develops and provides oversight of statewide program for injury prevention. • Performance Improvement Coordinator • Develops and provides oversight of statewide program for Performance Improvement activities. Registrar* Registrar* EMSIRS Regional Medical Director ** Provides oversight of compliance with trauma care guidelines at the regional level, conducts PI initiatives as indicated, communicates directives from the state and enhances to coordination of trauma care by establishing relationships and communications with EMS Medical Directors and Hospital representatives. Regional Coordinator ** Works with hospitals, Injury prevention, EMS and rehab facilities to form a network for regional trauma systems, promote communication, collaboration and integration of services, collaborates with regional medical directors to work on direct-ives, represents the region for the state. Epidemiologist * Collaborates with Injury Prevention Coordinator, PI coordinator and Trauma Registry Coordinator, to assess main outcome measures including Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. Biostatistician* Analyze data for clinical quality studies to improve delivery of trauma patient care throughout the spectrum including injury prevention, prehospital care, hospital care, and rehabilitation. RMD x 3-5 RC x 3-5

18. Projected Operating Expenses REVENUE (assuming a fee and expense structure similar to COTS) Funding From Hospitals (COTS Fee Schedule, for illustration purposes only) • Trauma Centers = 46 @ $22,000 = $ 1,012,000 • Non Trauma Center Hospitals/Free Standing ED= 161 @ $2,000 = $ 322,000 Total = $ 1,334,000 EXPENSES • Staff Development $30,000 (1.5 X COTS) = $ 45,000 • Supplies/Postage Mailing $26,000 (x 4) = $ 104,000 • Professional Fees $72,000 (x2) = $ 144,000 • Occupancy $79,000 (x1.5) = $ 118,000 • Marketing/Advertising $75,000 ( x 1) = $ 75,000 • Shared Admin $29,000 (x1.5) = $ 36,000 • Salaries and Benefits projected = $2,699,925 • Total = $3,221,925 Revenue – Expenses = (NET) (- $ 1,887,925)

19. Budget • Expense will be ~$3,200,000 • It is reasonable to expect trauma centers to provide some support as most of them already support regional trauma organizations • If COTS’ fee schedule is used=$1,012,000 • Many small rural hospitals operate on a very small margin • We recommend against requiring them to pay toward the system although a voluntary fee structure could be set up to allow donations • The Foundation should be charged with seeking funds from other sources including grants, endowments, donations • For every $1 of money raised that can be used for operational expenses (e.g. Grant money, interest from endowment), there would be a $0.50 reduction in the amount of support from the state

20. Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc. • Open forum for diverse (and otherwise competitive!) groups to come together – EMS, Trauma centers, Non-trauma centers, doctors, nurses, etc. • Regional educational programs – ATLS, Emergency Nursing Pediatric Course (ENPC®), the Trauma Nursing Core Curriculum (TNCC®) Course, and others • Regional guidelines/protocols • Burn surge plan, Regional mass movement of patients plan, Trauma alert criteria, Patient destination guidelines for multiple and mass casualty situations, Prehospital triage guidelines, Law enforcement & Hospitals: Carrying and Relinquishing Firearms, Regional Guidelines for Patients with Concealed Weapons, Regional Guidelines for Activation of the Surgical Emergency Response Team (SERT), Regional Guidelines for Acute Care Hospitals Trauma Performance Improvement, Regional Guidelines Regarding Patient calls To EMS for Transport from one Hospital to another hospital • Annual benchmarking reports and datasets for research

21. Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc. • COTS Bridges The Gap Between Diverse Health Systems And Institutions To Advance Regional Process Improvement • Providing assistance/education to trauma centers and acute care hospitals within the region, providing a forum to improve communication lines among Trauma Medical Directors, ED Medical Directors and EMS Medical Directors, serves as conduit between agencies providing care to the injured patient, identifies standard of care outliers and offers recommendations, provides consultative reviews for trauma care protocols and trauma patient transfer agreements (ORC 3727.09), provides surgical expertise for pre-hospital protocols and issues, serves as consultant for EMS peer review and quality assurance programs/issues (ORC 4765.12) • Advocacy and other Legislative Activity • Enforcing stricter penalties for texting while driving, improving accessibility to influenza vaccination for vulnerable populations by expanding EMS scope of practice, supports and actively engages in legislative initiatives to improve emergency care and injury prevention programming in Central Ohio • Manages regional trauma registry

22. Hospitals have realized these benefits to belonging to Central Ohio Trauma Systems, Inc. • Maintains the Hospital Emergency Departments’ Real-time Activity Status System (RTASS) to document incidents of EMS diversion and how busy EDs are in real-time. The system allows hospitals to immediately notify EMS when their EDs are overly busy or on divert status. • Provides hospitals educational opportunities including certification courses (i.e. ATLS, TNCC, ENPC etc), annual trauma research symposiums, guest speakers and other classes upon request (i.e. CEN Review and trauma data management courses) • On hospital request, attends Joint Commission Hospital Review to lend support and information demonstrating the hospital’s collaboration with other hospitals and healthcare entities on regional and statewide initiatives including disaster preparedness planning and exercising, shared services agreements, regional and state burn plans, regional and state pediatric surge plans and other regional healthcare improvement initiatives • Serves as an organization to deal with other time critical diagnoses, including stroke and STEMI