History of Trauma System Development in California

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

3. 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 18th & 19th Century Hospitals

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

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

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

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

27. 1970-1980 • Developing local Trauma Systems: • Los Angeles EMS • Orange EMS • San Diego EMS • Santa Clara EMS

28. 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

29. 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

30. 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

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

33. Trauma CenterCommitment • ALL departments • Trauma Surgeon • Other physicians • Critical care • Neurosurgery • Orthopedics • Plastics and ENT • Anesthesia • Radiology • Nurses • Every other staff member

34. Trauma Center Standards • Trauma Center • Designation standards • Data collection • Quality improvement protocols

35. 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%

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

37. The Infrastructure

38. Started 2005

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

40. The National Study on Costs and Outcomes of Trauma Center CareNSCOT 25% - Mortality Reduction <55

41. The LEMSA Model – A Story of Great Success

42. Why Not Everywhere

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

44. Percent of ISS > 15 Adult PatientsTreated at a Level I/II Center Missing Patients

45. 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.

46. 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

47. System Finance

48. Threats to Trauma Care Main Reason All Reasons

49. DespiteLegislative Support • Trauma Systems Reauthorization • Federal Agenda Inconsistent

50. 1980’s-1990’s • Several legislative proposals to provide funding for trauma care surfaced – most failed