State Trauma Advisory Council Level III Surgeon Criteria Work Group Final Report March 2013
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Table of Contents
Background ..................................................................................................................................... 3 Charge ............................................................................................................................................. 3 Membership .................................................................................................................................... 3 Summary and Recommendations ................................................................................................... 4 Charge #1: Evaluate how current general surgeon criteria are being operationalized ....... 4 Charge #2: Evaluate the proposal from Ridgeview Medical Center .................................. 6 Charge #3: Determine if changes are needed to the general surgeon criteria ..................... 7 Charge # 4: Make recommendations to the STAC for changes to the general surgeon criteria, if indicated. ............................................................................................................ 8 Concluding Comments.................................................................................................................. 12 References..................................................................................................................................... 13 Appendices.................................................................................................................................... 14 Appendix A: Ridgeview Letter......................................................................................... 15 Appendix B: Survey.......................................................................................................... 18 Appendix C: Survey Results............................................................................................. 24 Appendix D: Proposed Annotated Level III and IV Trauma Hospital Criteria ................ 49 Appendix E: Length of Stays............................................................................................ 62 2
Background
Ridgeview Medical Center, a level 3 trauma hospital, formally expressed their concerns about
the current response requirements for level 3 trauma hospitals with the STAC in their letter dated
May 11, 2011. The letter proposed to exempt level 3 hospitals from the requirement to have a
general surgeon continuously available to arrive in the emergency department within 30 minutes
of the patient’s arrival if a physician who is board-certified in emergency medicine is in-house
24/7 and the hospital is located within 30 minutes of a level 1 trauma hospital. Their main
concern, essentially, was over the reasonable, cost-effective and judicious use of scarce clinical
resources. The letter in its entirety along with the rationale is contained in Appendix A. While
the Ridgeview inquiry was very specific, the State Trauma Advisory Council seized the
opportunity to evaluate all of the criteria associated with the role of the general surgeon at level 3
trauma hospitals.
Charge
At their June 2011 meeting the State Trauma Advisory Council (STAC) approved the formation
of a work group to consider a proposal by Ridgeview Medical Center for the modification of the
current general surgeon response criteria and to assess the overall role of general surgeons at
level 3 trauma centers. The work group was charged to:
 Evaluate how current general surgeon criteria are being operationalized
 Evaluate the proposal from Ridgeview Medical Center
 Determine if changes are needed to the general surgeon criteria
 Make recommendations to the STAC for changes to the general surgeon criteria, if
indicated.
Membership
The multi-disciplinary work group membership consisted of both STAC members and trauma
care professionals with a special interest in this topic. The commissioner of the Minnesota
Department of Health acknowledges their patience, collaboration, respectful diplomacy and
dedicated effort in navigating this complex and controversial issue.
 Bill Heegaard, M.D., co-chair; emergency department physician, Hennepin County
Medical Center
 Chad Robbins, D.O.; co-chair; STAC member; general surgeon
 Kaysie Banton, M.D. (and earlier Matthew Byrnes, M.D.); general surgeon; University of
Minnesota Medical Center, Fairview, Minneapolis
 Todd Elftmann, M.D.; general surgeon; Ridgeview Medical Center, Waconia
 Carol Immermann, R.N.; STAC member; trauma program manager, Mayo Clinic—Saint
Mary’s Hospital, Rochester
 Mark Paulson, M.D.; STAC member; family medicine physician, Perham Health
 Shawn Roberts, M.D.; general surgeon; Riverwood Healthcare Center, Aitkin
 Kevin Sipprell, M.D.; emergency department physician; Ridgeview Medical Center,
Waconia
 Amanda Svir, R.N.; trauma program manager; Essentia Health St. Joseph’s Medical
Center, Brainerd
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Summary and Recommendations
The work group met initially in December 2011 and on five more occasions through February
2013. The members endeavored to maintain a patient-centric vision of the future that is
conscientious of the needs of the trauma system’s broad and varied stakeholder base, while
embracing the declared values of the trauma system:
All Minnesota hospitals will participate in a fully funded trauma system that:
 Is of the highest quality
 Is seamless across the continuum of care (prevention, care delivery, rehabilitation)
 Is safe, timely, efficient, patient-centered and patient-driven
 Uses outcome data and continuous clinical quality improvement to evolve
 Allows many trauma patients to be treated in their own communities
 Eliminates all delays in transfers to definitive care
 Is embraced and valued by citizens and policymakers
 Is fully integrated into the disaster preparedness and public health systems
The following is a summary of the work group’s assessments and recommendations.
Charge #1: Evaluate how current general surgeon criteria are being operationalized
To assess the current practice in Minnesota’s level 3 trauma center, the work group designed a
survey (Appendix B) that was distributed to all level 3 hospitals. Twenty five responded (86%)
and results were compiled both in aggregate and by region using the state’s Regional Trauma
Advisory Committee (RTAC) geographic boundaries. The survey revealed some notable
differences between the practices of metro hospitals versus rural hospitals.
 For the highest-level trauma activations (i.e., tier-one) requiring the surgeon to respond to
the emergency department within 30 minutes, few patients were transferred within 30
minutes of arrival (10%). More than half of these occurred in the metro RTAC.
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
Few surgical procedures were performed by the surgeon in the emergency department
(15%); most were chest tube insertions and airway procedures.
Procedure Insert Chest Tube
Insert Emergency Airway
Central Line
Arterial Line
Nasogastric Tube
Laceration Repair
Ankle Manipulation
Local Wound Exploration
Total

# 25
8
5
1
1
1
1
1
43
Few patients were taken directly from the emergency department to the operating room
(9%).
Procedure # Laceration repair/debridement
7
Exploratory lap
6
Active resuscitation w/ anesthesia
4
Gauging time for ortho to fix fracture
4
Open reduction
3
Splenectomy/spenic repair
3
Diaphragm repair
1
Finger amputation
1
Gunshot wound
1
Laproscopic facia repair from stab wounds 1
Partial colectomy
1
Venotomy repair
1
Total
33
5

A relatively large percentage of patients were admitted locally (48%). This was
considerably more common in the rural RTACs (47%) than in the metro RTAC (25%).

Few trauma patients admitted locally after a tier-one trauma activation were admitted
directly to the general surgeon (28%).
The survey also sought to gather subjective impressions from surgeons, emergency department
physicians and the trauma program managers regarding their perception of the importance of the
role played by general surgeons in trauma resuscitations at their respective facilities. Overall, the
requirement for the surgeon to respond to the trauma resuscitation within 30 minutes was felt to
be valuable by the rural hospitals and less valuable by those in the metro area. Generally, the role
played by general surgeons is considered valuable in their ability to perform procedures,
collaborating with the emergency physician and performing a trauma assessment. Their value
was not as universally clear in contributing to disposition decisions, interpreting diagnostic
results or assuming direct care of the trauma patient.
See Appendix C for the complete report of the survey results.
Charge #2: Evaluate the proposal from Ridgeview Medical Center
The work group determined that the proposal offered by Ridgeview Medical Center would
require two distinct sets of level 3 designation criteria, one for those hospitals near the Twin
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Cities and one for those further from the Twin Cities. The work group believes that this would
essentially create an additional level of trauma designation, effectively dividing level 3
designation into 3a and 3b. This creates a philosophical dichotomy as to what surgical resources
are beneficial to patients in a level 3 trauma center. It also assumes that the value of the surgeon
is marginalized when a physician certified by the American Board of Emergency Medicine is
present at the resuscitation; however, the work group found no clinical evidence to support this
assumption and anecdotal experience from trauma site visits may refute it.
While the work group generally agreed that the Ridgeview proposal was not viable, the majority
of work group members held that the current requirements for surgeon response could be
improved to reflect a more practical, cost-effective and judicious use of hospitals’ general
surgeon resources.
Charge #3: Determine if changes are needed to the general surgeon criteria
There are currently four indicators that compel the general surgeon to respond to the trauma
resuscitation in Minnesota’s level 3 trauma centers. They are (1) respiratory compromise/airway
obstruction and/or intubation (2) penetrating trauma to the abdomen, neck or chest (3) Glasgow
coma scale (GCS) < 8 with a primary etiology attributed to trauma (unless transfer out is
expected to occur within 30 minutes) and (4) two consecutive, pre-hospital systolic blood
pressures less than 90 mmHg in an adult or age-specific hypotension in children. Hospitals may
exceed these minimum requirements by adding criteria, but the surgeon must respond if any of
these four criteria are met. These response requirements were adapted from the requirements
established by the American College of Surgeons for level 3 trauma centers verified by the
College, which are the same criteria they establish for level 1 and 2 trauma centers.
While some members of the work group favored no change to the current criteria, the majority
contend that, while the current minimum response requirements may reflect logical criteria for
surgeon response in level 1 and 2 centers, they do not necessarily represent conditions that
surgeons in Minnesota’s level 3 centers are likely to impact substantially since they will transfer
virtually every one of these cases emergently. Focusing resources on stabilizing and rapidly
transferring these patients to a level 1 or 2 center is the highest priority. In such cases, the
surgeon’s presence in the emergency department often was not shown to offer additional benefit
to the patient beyond that of the emergency department physician sufficient to justify the
additional, and often substantial, costs incurred. Besides the financial impact, less tangible costs
must also be considered. Disruption of clinic and operating schedules and insufficient sleep
before a busy clinical day can affect the quality of health care delivered. Surgeons are also
understandably concerned about protecting their quality of life, wanting to reserve unscheduled
time away from their families for cases in which they can provide a material benefit to the
patient.
Still, providers at all levels are coming to appreciate the value of sometimes deploying resources
in excess of those ultimately required in order to be sufficiently prepared for the patients in
urgent need of those resources. The value of the surgeons’ expertise in the trauma resuscitation
cannot be overlooked. However, technological advancements have created an opportunity to
reconsider how to operationalize the surgeons’ involvement in trauma care at the level 3 trauma
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hospitals. The work group focused on better identifying the clinical conditions most likely to be
favorably affected by the presence and participation of the general surgeon and resolving the
balance between the surgeons’ intellectual contributions and physical presence.
Charge # 4: Make recommendations to the STAC for changes to the general surgeon
criteria, if indicated.
The work group recommends three major revisions and several minor changes to the level 3
surgeon response criteria. (See the entire document with the proposed changes marked up in
Appendix D.)
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2
Proposed Criteria Change
“The general surgeon must respond
by telephone and consult with the
emergency department provider
within 10 minutes of the arrival of a
patient meeting the highest-level
trauma activation criteria (i.e., tier
one criteria). The surgeon must then
arrive in the emergency department
within 30 minutes of the patient’s
arrival.”
“At the discretion of the emergency
department physician, the surgeon
may refrain from physically
responding to the emergency
department if:
• The surgeon continues to consult
with the emergency department
provider remotely until such time
that the patient is transferred, or the
patient has been stabilized and the
definitive disposition is determined;
and
• The surgeon has access to:
• dependable telephone service;
• the electronic medical record;
and
• virtual radiology
to assist in the consultative
process...”
Rationale
The first major revision recommendation is to
redefine the “surgeon response” to include telephone
consultation as a form of response. Compelling a
telephone consultation early in the case involves the
surgeon in the decision making early. This can key
the surgeon into the course the case is likely to take,
assist the emergency department provider in
prioritizing activities, hasten the decision to transfer
and predict the need for surgical procedures.
This pertains only to cases meeting tier-one trauma
activation criteria.
The second major revision is to permit the surgeon
to continue to provide telephone consultation
remotely if he/she has access to the technological
tools needed to provide a comprehensive
consultation. The availability of remote charting and
virtual radiology makes it possible for practitioners to
interact remotely. Much of the surgeon’s expertise is
intellectual in nature and can be provided by
telephone. If during the telephone consultation the
surgeon identifies the need to physically respond,
he/she can do so at that time. Additionally, few
patients go directly to the level 3 trauma centers’
operating room for lifesaving interventions; rather,
most lifesaving interventions are done in the
emergency department before the patient is
transferred to another facility. The emergency
provider and surgeon can collectively decide who
will perform the procedure during the telephone
consultation.
This pertains only to cases meeting tier-one trauma
activation criteria.
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3
4
Proposed Criteria Change
“…However, if the patient meeting
the highest-level trauma activation
criteria (i.e., tier one criteria) is
admitted, the surgeon must
physically respond to the hospital
and evaluate the patient within one
hour of the decision to admit.”
“If the surgeon provides remote
consultation but does not physically
respond to the emergency
department, he/she is still
considered an active care giver and
must document his/her involvement
in the medical record.”
Rationale
The objective of the above criteria is to spare the
surgeon a trip to the hospital when the patient is to be
emergently transferred while still providing the
patient with the benefit of the surgeon’s intellectual
expertise. If the patient will remain at the level 3
hospital, the surgeon should physically respond and
see the patient.
This pertains only to cases meeting tier-one trauma
activation criteria.
The surgeon’s participation in the case, even if by
telephone, should be documented in the medical
record so as to provide a complete and detailed
account of the decision making that occurred.
This pertains only to cases meeting tier-one trauma
activation criteria.
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5
Proposed Criteria Change
“The highest-level trauma
activation criteria must include (1)
respiratory distress, airway
obstruction or intubation; (2)
penetrating trauma to neck or torso;
(3) Glasgow Coma Scale (GCS)
score ≤8 from an etiology attributed
to trauma; (4) evidence of shock
indicated by two or more of the
following:
• heart rate >120 (or age-specific
tachycardia in pediatrics)
• systolic blood pressure <90
mmHg (pediatric: 70 + [2 x age
in years] mmHg)
• peripheral hypoperfusion
(capillary refill >2 seconds,
pallor)
• confusion
• tachypnea;
and (5) discretion of the emergency
department provider (for those
patients not meeting any of the
above criteria)”
Rationale
The third major revision is to modify the minimum
criteria for tier-one trauma activations. The revised
criterion adds “discretion of the emergency
department provider” to the list.
The work group also realized an opportunity to
improve the indicator for shock. Hemorrhagic shock
is surpassed only by head injuries as the leading
cause of traumatic deaths and is the leading cause of
trauma deaths in the first 48 hours following injury.
(Cocchi, Kimlin, Walsh, & Donnino, 2007) While
treatable, hemorrhagic shock is often recognized too
late. The surgeons’ unique training and skills are
particularly well suited to manage this condition,
perhaps more than any other condition represented by
the trauma activation indicators.
Traditional indicators identify shock as systolic blood
pressure less than 90 mmHg; however, the clinical
definition of shock is “inadequate tissue perfusion.”
Numerous studies have identified low blood pressure
as a late marker of shock and in pediatric patients,
occurring just prior to cardiac arrest. (Parks, Elliott,
& Gentilello, 2006) Others have suggested that
clinically significant hypoperfusion can be found in
patients with blood pressures approaching 110
mmHg. (Edelman, White, Tyburski, & Wilson, 2007)
(Risberg, et al., 1986) While the blood pressure is
immediately available to the resuscitation team, it
does not correspond well with other more sensitive
indicators of shock, such as lactate and base deficit
(Osbert Blow, 1999) (Callaway, Shapiro, Donnino, &
Baker, 2009), resulting in late recognition and high
mortality. Shock in trauma is most often hemorrhagic
in etiology and a blood pressure of less than 90
mmHg is associated with a mortality rate exceeding
50 percent. (Heckbert, et al., 1998) Its sensitivity is
even worse in elderly trauma patients. (Callaway,
Shapiro, Donnino, & Baker, 2009) The insidious
nature of shock makes it difficult to identify in its
early stages, but that is exactly what we must strive to
do if we are to impact trauma deaths from shock.
The work group recommends using a collection of
several subtle signs to predict the presence of shock.
While this criterion will likely result in some overtriage, the benefit of identifying potentially
salvageable patients earlier outweighs the cost.
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6
7
8
Proposed Criteria Change
“Eighty (80) percent of the time the
general surgeon’s response to the
resuscitation should meet the
response time requirements of the
trauma system.”
“Surgeon must be present at all
operative procedures performed in
the operating room.”
General surgeon training
requirement: "Effective January 1,
2015, must have successfully
completed ATLS and/or CALS
(including the Benchmark Lab or
Trauma Module Course) within the
last four years. Providers must re­
take their ATLS or CALS before or
during the month in which it
expires.”
“General surgeon representation
and participation in case reviews
9 and at the trauma performance
improvement (PI), peer review and
multidisciplinary committees.”
Required performance
improvement filter: “General
surgeon non-compliance to on-call
10
response times (level 3 only; both
physical and telephone response
requirements)”
Required performance
improvement filter: “General
surgeon consulted by phone for
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highest level trauma activation and
did not write a note in the medical
record (level 3 only)”
Rationale
This modification to the current criterion makes the
wording consistent with the surgeon response criteria
above.
This modification to the current criterion clarifies that
the surgeon must be present for procedures performed
in the operating room, but does not apply to surgical
procedures that are performed in the emergency
department, such as chest tube insertion and the
provision of a surgical airway.
The survey revealed that half of the state’s general
surgeons taking trauma call at level 3 hospitals had
taken an ATLS course within the last four years.
Trauma volumes are low at most level 3 facilities,
and the continuing education requirements for
surgeons to maintain board certification is insufficient
to maintain a current knowledge and competency in
trauma care. Surgeons are also expected to participate
in trauma case reviews for performance improvement
purposes. As leaders of the trauma team, the work
group believes that requiring surgeons to maintain
current trauma training is necessary to ensure that
providers are familiar with the ever-changing
standards of trauma care.
This modification to the existing criterion clarifies the
expectation that the general surgeons participate in
case reviews.
This modification to the existing filter clarifies that
the standard refers to only level 3 hospitals and
includes both telephone and physical response.
This new filter requires level 3 hospitals to track
compliance with the requirement for surgeons to
include a note in the medical record when they
provide a telephone consultation.
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Proposed Criteria Change
Required performance
improvement filter: “Length of stay
>60 minutes before transfer for
highest level trauma activation
(level 3 only)”
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Required performance
improvement filter: “Patient met
trauma transfer criteria and
admitted locally”
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Rationale
This new filter requires level 3 hospitals to monitor
patients’ length of stay in the emergency department
before transfer. Since surgeons may not physically
respond to the trauma resuscitation, cases in which
patients stay in the emergency department greater
than one hour must be reviewed through the
performance improvement process to determine if the
surgeon should have physically responded or if the
transfer was unnecessarily delayed. Registry data
indicates that patients often stay in level 3 emergency
departments for more than 60 minutes following a
trauma activation. (See Appendix E.)
This new filter is required for both level 3 and 4
trauma centers. Every trauma hospital has a transfer
policy that identifies patients by
anatomic/physiologic indicators whose condition
exceeds the resource capabilities of their hospital.
When one of these patients is admitted locally, the
trauma center should review the case to determine if
the admission represents an acceptable deviation to
the established practice expectation. The goal is to
encourage trauma centers to identify candidates for
emergent transfer early and expedite the transfer
process.
Concluding Comments
The members are to be commended for their efforts to see beyond their individual viewpoints to
appreciate each other’s perspectives and consider what is best for the trauma system as a whole.
The conclusions and recommendations contained in this document were arrived at through
negotiation and compromise. For every individual recommendation represented above, the work
group deliberated over numerous options, the majority of members ultimately arriving at these
recommendations through a consensus building process.
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References
Callaway, D. W., Shapiro, N. I., Donnino, M. W., & Baker, C. M. (2009). Serum Lactate and
Base Deficit as Predictors of Mortality in Normotensive Elderly Blunt Trauma Patients.
The Journal of Trauma, Infection, and Critical Care, 1040-1044.
Cocchi, M. N., Kimlin, E. M., Walsh, M. M., & Donnino, M. W. (2007). Identification and
Resuscitation of the Trauma Patient in Shock. Emergency Medicine Clinics of North
America, 623-642.
Demetriades, D. M., Kimbrell, B. M., Salim, A. M., Velmahos, G. M., Rhee, P. M., Preston, C.
R., et al. (2005). Trauma Deaths in a Mature Urban Trauma System: Is "Trimodal"
Distribution a Valid Concept? Journal of the American College of Surgeons, 343-348.
Edelman, D. A., White, M. T., Tyburski, J. G., & Wilson, a. R. (2007). Post-Traumatic
Hypotension: Should Systolic Blood Pressure of 90-109 mmHg be Included? Shock, 134­
138.
Heckbert, S. R., Vedder, N. B., Hoffman, W. R., Winn, R. K., Hudson, L. D., Jurkovich, G. J., et
al. (1998). Outcome after Hemorrhagic Shock in Trauma Patients. The Journal of
Trauma, Injury, Infection, and Critical Care, 545-549.
Kauvar, D. S., Lefering, R. P., & and Wade, C. E. (2006). Impact of Hemorrhage on Trauma
Outcome: An Overview of Epidemiology, Clinical Presentations, and Therapeutic
Considerations. The Journal of Trauma, Injury, Injection, and Critical Care, S3-S11.
Osbert Blow, M. P. (1999). The Golden Hour and the Silver Day: Detection and Correction of
Occult Hypoperfusion within 24 Hours Improves Outcome from Major Trauma. The
Journal of Trauma: Injury, Infection, and Critical Care, 965-969.
Parks, J. K., Elliott, A. C., & Gentilello, L. M. (2006). Systemic hypotension is a late marker of
shock after trauma: a validation study of Advanced Trauma Life Support principles in a
large national sample. The American Journal of Surgery, 727-731.
Risberg, B. M., Medegard, A. M., Heideman, M. M., Gyzander, E. B., Bundsen, P. M., Oden, M.
M., et al. (1986). Early activation of humoral proteolytic systems in patients with
multiple trauma. Critical Care Medicine, 917-925.
Victorino, G. P., Battistella, F. D., & Wisner, D. H. (2003). Does Tachycardia Correlate with
Hypotension after Trauma? Journal of the American College of Surgery, 679-684.
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Appendices
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Appendix A: Ridgeview Letter
500 South Maple Street  Waconia, MN 55387-1791
952/442-2191 800/967-4620
May 11, 2011
Tim Held
Trauma Systems Coordinator Minnesota Department of Health Community Health Division
Metro Square Building- Suite 460
121 East Seventh Place
P.O. Box 64975
St. Paul, MN 55164-0975
Dear Tim,
Thank you for taking the time to meet with representatives from Ridgeview Medical Center
regarding the state trauma system, and in particular the Level lII classification. Ridgeview
Medical Center believes the state trauma system cm be most effective when it constantly
evaluates and updates the system to meet the needs of both providers and patients.
We would propose a change to the Level Ill, classification that meets these value statements.
•
Is safe, timely, efficient, patient centered, and patient driven
•
Eliminates all delays and transfers to definitive care
•
Is mindful of overall system costs and scarce specialist resources
•
A trauma care system that is based on obtaining the best outcome for injured patients
Background Information
At Ridgeview Medical Center we strongly believe that not all Level III trauma centers can be
routinely categorized under one set of standards.
For example, the Level Ill trauma centers located in the Minneapolis and St. Paul metro area and
within close driving distance to a Level l trauma center can and should triage patients differently
than those Level III trauma centers located significant distances away from a Level l trauma
center.
15
Ridgeview Medical Center is within 30 minutes of two Level l trauma centers. In these cases, we
will look to appropriately triage patients as quickly as possible to Level l trauma centers or directly
from the field. It does not make sense to call in a general surgeon when a transfer is imminent.
Yet, we need to activate them at the same time we activate our entire trauma team
to meet the 30 minute requirement.
In 2010 Ridgeview Medical Center had over 21,000 emergency department visits. During that
same time period trauma team activation was called 21times. Of those, 9 were transferred to a
Level l, 3 patients died, 3 were discharged because of being over triaged, and 6 were admitted
to Ridgeview Medical Center. A further assessment of the 9 trauma patients that were transferred
and the 6 that were admitted to Ridgeview showed no involvement by the general surgeon. 14 of
the 15 cases the general surgeon was on-site within the 30 minute requirement
Ridgeview Medical Center has in house board certified emergency physicians. These board
certified emergency room physicians are skilled in the care of trauma patients. They are trained to
determined if a pt needs immediate surgical interventions and are capable of performing
emergent, possibly life-saving, bedside interventions if needed.
Ridgeview Medical Center has four board certified general surgeons on-call. These general
surgeons do not practice trauma surgery.
Even though we have a limited number of trauma team activations our general surgeons are now
requesting to be paid for being available within a 30 minute notice. Prior to this, surgeons would
consult on the telephone with our emergency room physicians to determine the extent of which
they would be required to see a patient and within what time frame.
The requirement to have a general surgeon present within 30 minutes is leading towards an
unnecessary cost in regards to compensation for general surgeons to be readily available within the
30 minute timeframe. This is not a good utilization of a general surgeon's time when care required
by the trauma patient is being delivered by the board certified emergency room physician.
Proposal
Ridgeview Medical Center would propose that Level III trauma center hospitals that have in house
board certified emergency room physicians (24/7) and are located within 30 minutes of Level l
trauma center be exempt in the requirement of having a general surgeon available within 30
minutes of the trauma team activation.
The rationale is that the board certified emergency room physicians in Level ill trauma centers are
in the best position to determine when the services of the general surgeon are required. Our
general surgeons are prepared and willing to come to the hospital when called but the requirement
is unnecessary and burdensome.
In Level Ill trauma centers that are located greater distances away from a Level l trauma center it
may very well be appropriate for them to have the general surgeon 30 minute requirement in
place.
Both types of institutions deserve to be called Level III trauma centers, it would be unfair to ask
Ridgeview Medical Center to drop its designation down to Level IV when clearly Ridgeview is
16
providing care to trauma patients at or above the requirements for a Level lII trauma center
designation.
Summary
We believe the changes we have requested are reasonable and in the best interest of our state
trauma system, local hospital system and the scarce resources available, both in terms of
money and time. We believe that a singular approach to Level Ill to trauma centers does not
accurately reflect the uniqueness of healthcare within the state of Minnesota and particularly the
providers that are on the front lines delivering trauma care to patients. We would be pleased to be
able to present in person should that be necessary to the Minnesota State Trauma Council. I look
forward to your response.
Cc: David Larson, MD- Medical Director Ridgeview Emergency Room Services
Laresa DeBoer,MD- Asst. Medical Director Ridgeview Emergency Room Services
Kevin Sipprell, MD- Ridgeview EMS Medical Director
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Appendix B: Survey
Section 1: Operational Survey
This section is to be filled out by the Trauma Program Manager or Trauma Medical Director. Hospital Name______________________________ Hospital County_____________________________ 1. How many tier-1 (i.e., the highest level of activation) Trauma Team Activations (TTA’s)
occurred in your hospital in calendar year 2011?
Number________
2. How many tier-1 TTAs in 2011 involved a surgical procedure performed by a general
surgeon in the ED. (A “surgical procedure” includes insertion of a chest tube or central line,
surgical airway, thoracotomy, cut down, peritoneal lavage, etc. It does not include peripheral
IVs.)
Number________
a. For these tier-1 TTAs, please list all procedures performed by the surgeon in the ED
and the number of times each one was performed by a general surgeon.
Number of times
Procedure
performed
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3. Of the tier-1 TTAs in 2011, how many involved patients going directly from the ED to the
OR?
Number________
a. For these tier-1 TTAs, please list all procedures performed by the surgeon in the OR
and the number of times each one was performed by a general surgeon.
Number of times
Procedure
performed
4. Of the tier-1 TTAs in 2011, how many patients were admitted to the hospital?
Number________
a. Of those admitted, how many patients were admitted to the general surgeon?
Number________
5. Of the tier-1 TTAs in 2011, how many patients were transferred to another acute care
hospital from the ER?
Number________
a. Of those transferred how many were transferred within 30 minutes of arrival to the
ED (meeting the state’s exception requirement for the general surgeon to arrive
within 30 minutes of patient arrival)?
Number________
6. How many general surgeons cover trauma call at your facility?
Number________
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8. Do surgeons typically cover trauma and/or surgical call at other hospitals concurrently with
trauma call at your facility? (circle one)
Yes
No
Unknown
9. How many of the general surgeons that cover trauma call at your facility have taken ATLS or
CALS within the last four years?
Number________
10. Do you provide additional compensation to your general surgeons for taking trauma call?
(circle one)
Yes
No
11. The emergency department is staffed by: (indicate percentages)
a. Emergency physicians certified by the American Board of Emergency Medicine
(ABEM) or the American Board of Pediatrics (ABP) (or osteopathic equivalent)
dedicated to the ED
______%
b. Emergency physicians certified by the American Board of Family Medicine (or
osteopathic equivalent) or other non-ABEM/non-ABP board, dedicated to the ED
______%
c. Clinic physicians who take turns covering the emergency department while in clinic
and on call after hours
______%
20
Section 2: Trauma Program Manager Questionnaire
This section is to be filled out by the Trauma Program Manager at your facility.
For each of the following functions, indicate your impression of the importance of the role
played by general surgeons in trauma resuscitations at your facility (circle one).
Ability to perform procedures
not at all
important
1
2
3
very
important
4
5
Disposition decisions (e.g. transfers, admissions)
1
2
3
4
5
Interpretation of diagnostic results (e.g. lab, imaging,
etc…)
1
2
3
4
5
Assuming direct care of patient in ED
1
2
3
4
5
Providing collaborative care with ED physician
1
2
3
4
5
Trauma assessment
1
2
3
4
5
Please list and describe any other role general surgeons play in trauma resuscitations at your
facility.
In your opinion, what is the value of the requirement for level 3 designated trauma facilities to
have a general surgeon arrive within 30 minutes of patient arrival when a tier-1 TTA is called
(circle one):
No Value
Value
1
Great
2
3
4
5
21
Section 3: General Surgeon Questionnaire
This section is to be filled out by the General Surgeon who most often responds to tier-1 TTAs at
your facility.
For each of the following functions, indicate your impression of the importance of the role
played by general surgeons in trauma resuscitations at your facility (circle one).
Ability to perform procedures
not at all
important
1
2
3
very
important
4
5
Disposition decisions (e.g. transfers, admissions)
1
2
3
4
5
Interpretation of diagnostic results (e.g. lab, imaging,
etc…)
1
2
3
4
5
Assuming direct care of patient in ED
1
2
3
4
5
Providing collaborative care with ED physician
1
2
3
4
5
Trauma assessment
1
2
3
4
5
Please list and describe any other role general surgeons play in trauma resuscitations at your
facility.
In your opinion, what is the value of the requirement for level 3 designated trauma facilities to
have a general surgeon arrive within 30 minutes of patient arrival when a tier-1 TTA is called
(circle one):
No Value
Value
1
Great
2
3
4
5
22
Section 4: Emergency Physician Questionnaire
This section is to be filled out by an Emergency Physician who responds to tier-1 TTAs at your
facility.
For each of the following functions, indicate your impression of the importance of the role
played by general surgeons in trauma resuscitations at your facility (circle one).
Ability to perform procedures
not at all
important
1
2
3
very
important
4
5
Disposition decisions (e.g. transfers, admissions)
1
2
3
4
5
Interpretation of diagnostic results (e.g. lab, imaging,
etc…)
1
2
3
4
5
Assuming direct care of patient in ED
1
2
3
4
5
Providing collaborative care with ED physician
1
2
3
4
5
Trauma assessment
1
2
3
4
5
Please list and describe any other role general surgeons play in trauma resuscitations at your
facility.
In your opinion, what is the value of the requirement for level 3 designated trauma facilities to
have a general surgeon arrive within 30 minutes of patient arrival when a tier-1 TTA is called
(circle one):
No Value
Value
1
Great
2
3
4
5
23
Appendix C: Survey Results
Level III Trauma Center General Surgeon Survey Hospitals Surveyed • Sent to 29 Level III hospitals – 25 responded – 86% response rate • RTACs represented –
–
–
–
–
–
11 METRO* 5 CENTRAC 3 NERTAC 3 SWRTAC 2 SMRTAC 1 WESTAC *(One excluded from TTA counts due to reporting error) 24
Hospitals Surveyed SHORTNAME RTAC Abbott‐Northwestern METRO RESPONDED TO SURVEY 1
Fairview ‐ Ridges METRO 1
Lakeview ‐ Stillwater METRO 1
Methodist METRO 1
Ridgeview ‐ Waconia METRO 1
St. Francis – Shakopee* METRO 1
St. John's METRO 1
St. Joseph's St. Paul METRO 1
United ‐ St. Paul METRO 1
Unity METRO 1
Woodwinds METRO 1
Buffalo CENTRAC 1
Cuyuna CENTRAC 1
Essentia ‐ St. Josephs ‐ Brainerd CENTRAC 1
Fairview ‐ Lakes CENTRAC 1
Lakewood CENTRAC 1
Fairview ‐ Mesabi NERTAC 1
Grand Itasca NERTAC 1
Riverwood NERTAC 1
Glencoe SWRTAC 1
Rice Memorial SWRTAC 1
Sanford ‐ Worthington SWRTAC 1
Fairview ‐ Red Wing SMRTAC 1
Mayo ‐ Mankato SMRTAC 1
Douglas County WESTAC 1
Children's Minneapolis METRO 0
Children's St. Paul METRO 0
Avera Marshall SWRTAC 0
Essentia St. Marys ‐ Detroit Lakes WESTAC 0
*(Excluded from TTA counts due to reporting error) Tier I Trauma Team Activations (TTAs)
Number of Tier I Trauma Team
Mean Median Range
Hospitals
Activations
Statewide
24
267 11.1
10 0-49
Non-Metro
13 0-49
14
202 14.4
6.5
Metro
65
10
7 2-12
*(St. Francis in Shakopee excluded from TTA counts due to reporting error) 25
TTAs with Surgical Procedure Performed in the ED • 41 TTAs w/ surgeon performing procedure – Median = 1 – Mean = 1.7 – Range = 0‐12 12 4 4 CENTRAC METRO 7 7 7 NERTAC SMRTAC SWRTAC WESTAC Surgical Procedures Performed by the Surgeon in the Emergency Department "For these tier‐1 TTAs, list all procedures performed by the surgeon in the ED and the number of times each one was performed by a general surgeon. "
Insert Chest Tube 25 Insert Emergency Airway 8 Central Line 5 Arterial Line 1 Nasogastric Tube 1 Laceration Repair 1 Ankle Manipulation 1 Local Wound Exploration 1 Total
43
26
TTAs w/ patient going directly from ED to OR • 24 TTAs ED to OR 7 – Median = 1 – Mean = 1 – Range = 0‐24 7 5 2 2
SWRTAC WESTAC 1 CENTRAC METRO NERTAC SMRTAC Procedures Performed When Admitted Directly From the ER to the OR "For these tier‐1 TTAs, list all procedures performed by the surgeon in the OR and the number of times each one was performed by a general surgeon. " Laceration repair/debridement Exploratory lap Active resuscitation w/ anesthesia Gauging time for ortho to fix fracture Open reduction Splenectomy/spenic repair Diaphragm repair Finger amputation Gun shot wound Laproscopic facia repair from stab wounds Partial cloectomy Venotomy repair Total
7 6 4 4 3 3 1 1 1 1 1 1 33
27
Admissions from TTAs in 2011 • 111 TTAs w/ hospital admissions – Median = 2 – Mean = 4.8 – Range 0 ‐ 32 32 26
25 16
8 4 CENTRAC METRO NERTAC SMRTAC SWRTAC WESTAC Admissions directly to General Surgeon • 76 TTAs w/ admits to GS – Median = 1 – Mean = 3.3 – Range = 0‐16 26 15 15 13 4 CENTRAC METRO NERTAC 3 SMRTAC SWRTAC WESTAC 28
TTAs transferred to another hospital • 126 TTAs transferred 35 – Median = 10 – Mean = 11 – Range = 0‐49 25 22 17 CENTRAC METRO 14 13
NERTAC SMRTAC SWRTAC WESTAC TTAs transferred w/in 30 minutes • 28 TTAs w/ 30 min transfer – Median = 0 – Mean = 1 – Range = 0‐7 16 6 2 CENTRAC METRO NERTAC 3 1 SMRTAC 0 SWRTAC WESTAC 29
Responses to TTAs at Non‐Metro vs. Metro Hospitals NON‐METRO METRO 100.0 90.0 Percent of all TTAs in 2011 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Surgical Procedure done Patient Sent Directly from ED to OR by Surgeon Patient Admitted to Hospital Patient Admitted to General Surgeon Patient Transferred to Another Hospital Patient Transferred within 30 Minutes of Arrival Number of General Surgeons covering trauma call •
•
•
•
123 surgeons at 25 hospitals Mean = 4.9 Median = 4 Range = 0 – 10 Metro, 62 Non‐Metro, 61 *(St. Francis in Shakopee excluded from TTA counts due to reporting error) 30
General Surgeons with ATLS/CALS • 62/123 (50%) surgeons have taken ATLS/CALS w/in last 4 years Percent of Surgeons Covering Call with ATLS/CALS in Past 4 Years 74% 73% 67% 54% 45% 37% CENTRAC METRO NERTAC SMRTAC SWRTAC WESTAC Percent of General Surgeons covering call with ATLS/CALS in past 4 years 64 37 Non‐Metro Metro 31
Additional compensation for trauma call • No = 14/25 (56%) • Yes = 11/25 (44%) Percent of Hospitals Paying Additional Compensation for Trauma Call 82 50 20 0 CENTRAC METRO NERTAC SMRTAC 0 0 SWRTAC WESTAC Percent of hospitals providing additional compensation for trauma call 82 14 Non‐Metro Metro 32
Hospitals reporting that their surgeons take call at multiple facilities simultaneously • No = 16/24 (67%) • Yes = 8/24 (33%) Double Call
No
CENTRAC
METRO
NERTAC
SMRTAC
SW RTAC
W ESTAC
Total
Yes
3
6
2
2
2
1
16
Total
2
4
1
0
1
0
8
% of total
5
40
10
40
3
33
2
0
3
33
1
0
24
33
ER coverage by ABEM or ABP certified physicians • Metro – 10/11 hospitals have 80‐100% of coverage by ABEM or ABP certified physicians – 1/11 has 80‐100% coverage by ABMF or other • Non‐Metro – 3/13 has 80‐100% of coverage by ABEM or ABP – 8/13 has 80‐100% of coverage by ABFM or other – 2/13 have a mix of ABEM, ABFM, and Clinic Physicians 33
ER Coverage STATEWIDE
0-19 Perc ent
20-39 Percent
40-59 Percent
60-79 Percent
80-100 Percent
Number of Hospitals
ABEM or ABP ABFM or other Clinic Physician s
1
10
11
0
0
0
0
0
0
0
0
0
10
1
0
11
11
11
METRO
0-19 Percent
20-39 Percent
40-59 Percent
60-79 Percent
80-100 Percent
Number of Hos pitals
ABEM or ABP ABFM or othe r Clinic Physician s
1
10
11
0
0
0
0
0
0
0
0
0
10
1
0
11
11
11
NON-METRO
0-19 Percent
20-39 Percent
40-59 Percent
60-79 Percent
80-100 Percent
Number of Hos pit als
ABEM or ABP ABFM or other Clinic Physician s
7
2
12
1
0
1
2
1
0
0
2
0
3
8
0
13
13
13
Provider Questionnaires • For each of the following functions, indicate your impression of the importance of the role played by general surgeons in trauma resuscitations at your facility: • No Value Great Value • 1 2 3 4 5 34
Ability to Perform Procedures Trauma Program Manager General Surgeon ER Physician 13 11 9 8 6 5 5 3 2 1 2 2 2 3 4 1 0 1 2 5 Ability to Perform Procedures Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5
4 3 2 1 0 General Surgeon ER Physician 10 10
8
2
0
0
0
0
1 3 1
1
2 0
1
3 4
2
4 5 Non‐Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 General Surgeon ER Physician 6
4
1
0
1 1
2
2
2 1
2
4
2
2
2
2
0
3 4 5 Metro 35
Disposition Decisions Trauma Program Manager General Surgeon ER Physician 11 11 8 8 6 6 5 3 3 2 2 1 1 2 1 1 2 3 4 5 Disposition Decisions Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 3
0
0
2 3
General Surgeon 4
1 2 5
4
5
2 1
0
ER Physician 3 6
5
2 4 5 Non‐Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 General Surgeon ER Physician 6 4 1 1 1 1 2 1 2 2 4 1 3 4 0 1 4 4 0 5 Metro 36
Interpretation of Diagnostic Results Trauma Program Manager General Surgeon ER Physician 9 8 7 6 6 5 4 4 4 4 4 4 3 2 0 1 2 3 4 5 Interpretation of Diagnostic Results Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5
4 3
2 1 0 4
1
0
0
1
1 General Surgeon 5 4 3
0
2 ER Physician 6
2 3 5 5 4 2 4 5 Non‐Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 4 2 3 4 0 1 General Surgeon 4 0 2 1 2 3 3 ER Physician 3 2 2 0 4 1 5 Metro 37
Assuming Direct Care of Patient in ED Trauma Program Manager General Surgeon ER Physician 8 7 7 7 6 6 4 3 3 3 3 4 4 3 2 1 2 3 4 5 Assuming direct care of patient in ED Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 2 1 1 1 2 2 2 6 1 2 4 5 4 2 5 4 Non‐Metro General Surgeon ER Physician 5 4 2 2 3 3 Trauma Program Manager ER Physician 6 5 1 10 9 8 7 6 5 4 3 2 1 0 General Surgeon 3 2 1 2 1 1 3 2 1 4 0 1 1 1 5 Metro 38
Collaborative Care with ED Physician Trauma Program Manager General Surgeon ER Physician 14 11 11 6 6 5 5 4 1 0 1 1 4 1 0 1 2 3 4 5 Collaboration with ED Physician Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 General Surgeon ER Physician 8
9 8 5
0
0
0
0
1 0
1
1
2 2
3 2
3 3 4 5 Non‐Metro Trauma Program Manager 10 9 8 7 6 5
4 3 2 1 0 General Surgeon ER Physician 7
4
0
0
1 1
1
1
2 4 4
2
0
3 1
2
4 3 1
5 Metro 39
Trauma Assessment Trauma Program Manager General Surgeon ER Physician 9 8 8 8 5 4 3 8 5 4 3 2 2 1 0 1 2 3 4 5 Trauma Assessment Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6
5 4 3 2 1 0 ER Physician 7 3
0
0
0
0
1 0
1
2 3 1
2 2 0
1 2 4 2 2 4 1 7 4 4 Non‐Metro General Surgeon 2 8 2 3 Trauma Program Manager 10 9 8 7 6 5
4
3
2 1 0 General Surgeon 3 3 4 5 ER Physician 4 1 4 2 2 2 5 Metro 40
Value of 30 Minute Requirement • In your opinion, what is the value of the requirement for level 3 designated trauma facilities to have a general surgeon arrive within 30 minutes of patient arrival when a tier‐1 TTA is called (circle 1): No Value Great Value 1 2 3 4
5 Value of 30 Minute Requirement Trauma Program Manager General Surgeon ER Physician 10 9 7 7 6 5 4 2 2 5 4 4 2 2 1 1 2 3 4 5 41
Value of 30 Minute Requirement Non‐Metro vs. Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 General Surgeon ER Physician 7 0 1 0 1 1 2 2 4 2 1 0 2 4 3 8 7 3 4 5 Non‐Metro Trauma Program Manager 10 9 8 7 6 5 4 3 2 1 0 1 3
2
1 1 2
2 2
General Surgeon 3
ER Physician 4
4
1 3 0 3
3
1 1
4 5 Metro TPM: Value of 30 minute GS arrival requirement Trauma Program Managers: Value of requirement for level 3 designated trauma facilities to have a general surgeon arrive within 30 minutes of patient arrival when a tier‐1 TTA is called 9 5 4 4 1 No Value Great Value 42
GS: Value of 30 minute GS arrival requirement General Surgeons: Value of requirement for level 3 designated trauma facilities to have a general surgeon arrive within 30 minutes of patient arrival when a tier‐1 TTA is called 7 7 5 2 2 No Value Great Value ER: Value of 30 minute GS arrival requirement ER Physicians: Value of requirement for level 3 designated trauma facilities to have a general surgeon arrive within 30 minutes of patient arrival when a tier‐1 TTA is called 10 6 4 2 No Value 2 Great Value 43
Number of General Surgeons covering trauma call •
•
•
•
120 surgeons at 23 hospitals Median = 4 Mean = 5 Range = 0 – 10 59 23
11 13 11 3 CENTRAC METRO NERTAC SMRTAC SWRTAC WESTAC Surgeons taking call at multiple facilities simultaneously • Double Call Percent of Hospitals with Surgeons Covering Double Call by Region – No = 16/24 (67%) – Yes = 8/24 (33%) 33 33 0 CENTRAC METRO NERTAC 0 SMRTAC SWRTAC WESTAC Double Call
No
CENTRAC
METRO
NERTAC
SMRTAC
SWRTAC
WESTAC
Total
Yes
3
6
2
2
2
1
16
Total
2
4
1
0
1
0
8
5
10
3
2
3
1
24
% of total
40
40
33
0
33
0
33
44
Additional Compensation for Trauma Call • Additional Comp – No = 14/24 (58%) – Yes = 10/24 (42%) Percent of Hospitals Paying Additional Compensation for Trauma Call 80
50 20 0 CENTRAC METRO Additional Comp
No
CENTRAC
METRO
NERTAC
SMRTAC
SWRTAC
WESTAC
Total
NERTAC SMRTAC Yes
4
2
3
1
3
1
14
0 0 SWRTAC WESTAC Total
1
8
0
1
0
0
10
5
10
3
2
3
1
24
% of total
20
80
0
50
0
0
42
General Surgeons with ATLS/CALS • 59/120 (49%) surgeons have taken ATLS/CALS w/in last 4 years Percent of Surgeons Covering Call with ATLS/CALS in Past 4 Years 74% 73% 67% 54% 45% 37% CENTRAC METRO NERTAC SMRTAC SWRTAC WESTAC 45
“Please list and describe any other role general surgeons play in trauma resuscitations at
your facility”
Location
Metro
Metro
Trauma Program Manager
Need to be in the ED if
patient is in the Department
at minute 31 after arrival
None
Metro
Collaboration and support for
the EC MD. Not used often
for procedures. There is
always 2-5 boarded EC MD’s
at any given time.
Metro
If in house they show up to
ED tertiary exam, if NS
taking to OR. None, some go
to OR, Exams mainly
involved in transfering.
We have many capable ED
providers 100% ATLS
trained. TS's are available
quickly when their services
are required. The trauma
surgeons call on right away
to discuss the case and
collaborate with the ED
physicians ove the phone
prior to their arrival. I feel that
it is important to have a
General Surgeon available
as soon as they can possibly
get there. I feel it is importnat
to have a goal time but must
review every case
individually adn with scrutiny.
our ED physicinas are way
experienced & TS are very
involved int eh care we
provide as well as in
performance improvement.
Metro
Ring
General Surgeon
The general surgeons
play a crucial role for tier-I
TTA’s, both in regard to
collaboration in the ED
and admission to the
hospital for treatment.
However, we have
relatively few tier-I TTA’s;
for most trauma patients,
our role is supportive.
Emergency Physician
In general, the general surgeons
have little active role in the
evaluation and resuscitation of our
trauma patients. However, their
input on disposition is greatly
valued and their presence could
be very important in a rare
instance when a surgical
intervention is required in the ER
Providing support as needed, to
the ER Physician. In operative
cases, determining need for
transfer to Level I trauma center.
ED MD runs trauma
resuscitations. General
surgeons available but
rare need for interventions
other than operative.
Collaborative relationship
between ED & surgeons.
Collaborative approach during
initial Tier I resuscitation. General
surgery instrumental in decision
making of significant traumas.
Chest tube management,
triage of pts prior to
transfer”
Helpful as 2nd provider if
numerous procedures
46 Location
Ring
Trauma Program Manager
None.
General Surgeon
None.
Rural
Rural
Rural
Rural
Rural
Rural
Emergency Physician
See non-TTA admitted patients on
the floor. No other role during
TTA.
We are solo coverage in our ED.
The extra help of a provider with
experience and interest in trauma
is valuable
Operative management
We have a busy emergency
department and it is a huge
asset to know our general
surgeon is available and
willing to come and care for
the patient being admitted or
transferred. All surgeons are
hands-on and willing to step
in and take on any role
needed. Ultimately, having a
surgeon immediately at
bedside for all trauma alerts
is the best for trauma
patients and all patients in
our emergency department.
None
They lead the trauma team
collaboratively with ED
physicians. They often
assume care so the ED can
care for CVAs, Mis and other
ED critical pts
We had a recent
thoracotomy done in the ER
by a general surgeon that
was a lifesaving procedure
which enabled the patient to
make it to the receiving
facility. She would have
otherwise died in our ER if
not for the surgeon.
At our facility the general
surgeons take command
of the resuscitation once
they arrive
The ability to have our surgeons
present for trauma codes
improves patient flow, provides
collaborative evaluation with
coordination/delegation of specific
resuscitation measures. This is
invaluable to care of trauma
patients in a facility our size
None
None
Communication with prehospital personnel for
multi-victim triage.
Education to staff à
debriefings
Review of cases and leading
trauma review for everyone’s
education. Leading by example
Rural
Seen in all Level I trauma
Rural
Facilitates transfers.
Performance evaluation.
Rural
Team leader
Rural
Work collaboratively with ER
physicians. Surgeon acts as
consultant. ER physician
manages care and transfer
details.
Triage in multiple victim
situations. Utilization of
diagnostic procedures.
Early coordination of
evaluation, treatment, and
disposition of patients
Depends on the general surgeon
Ability of surgeon to go to
scene of trauma.
47 Location
Trauma Program Manager
General Surgeon
Emergency Physician
Rural
Most is by ER provider.
Surgeon rarely needed for
procedures. Commonly pt
is shipped due to lack of
resources at small rural
hospital, ie no surgery, no
ortho, mostly to the major
facility.
Main roles would be admitting
traumas that don't require
immediate surgery but need
ongoing assessment (spleen &
liver lacs). Stabilizing
laparotomies prior to transfer in
critical pt's and isolated abd
trauma.
Rural
Case review.
"We really appreciate gen surgery
presence for tier I TTA. Pleas do
not change this policy. It really
makes a difference for the
severely injured."
48 Appendix D: Proposed Annotated Level III and IV Trauma Hospital Criteria All proposed changes are in bold; additions are underlined, deletions are struck through
Institutional Organization
Program Component
Level
III
Level
IV
Hospital Commitment
E
E
Trauma Program
E
E
E
E
E
NA
NA
E
Trauma Team Activation
Criteria Description
The board of directors, administration, and medical, nursing and ancillary staff shall make a
commitment to providing trauma care commensurate to the level at which the facility is applying for
categorization and or is verified.
The trauma program shall be established by the facility with approval from the medical staff, board of
trustees, and administration, and represented on an organizational chart. This may be in conjunction
with an existing department; for example, emergency or surgery appropriate.
Trauma hospitals shall have a trauma team activation protocol/policy to include:
 Lists of all team members
 Response requirements for all team members when a trauma patient is en route or has arrived
 The criteria, based on patient severity of injury, for activation of the trauma team and the
person(s) authorized to activate the trauma team
The trauma team activation policy shall include both physiological and anatomical clinical indicators
for when the ED physician is expected to be present in the ED within 15 minutes of EMS notification.
The trauma team activation policy shall include both physiological and anatomical clinical indicators
for when the on-call medical provider covering the ED is expected to be present in the ED within 30
minutes of EMS notification.
49
Program Component
Level
III
Level
IV
Criteria Description
The general surgeon must respond by telephone and consult with the emergency department
provider within 10 minutes of the arrival of a patient meeting the highest-level trauma
activation criteria (i.e., tier one criteria). The surgeon must then arrive in the emergency
department within 30 minutes of the patient’s arrival.
Trauma Team Activation
(cont’d)
E
NA
At the discretion of the emergency department physician, the surgeon may refrain from
physically responding to the emergency department if:
 The surgeon continues to consult with the emergency department provider
remotely until such time that the patient is transferred, or the patient has been
stabilized and the definitive disposition is determined1; and
 The surgeon has access to:
o dependable telephone service;
o the electronic medical record; and
o virtual radiology
to assist in the consultative process.
However, if the patient meeting the highest-level trauma activation criteria (i.e., tier one
criteria) is admitted, the surgeon must physically respond to the hospital and evaluate the
patient within one hour of the decision to admit.
If the surgeon provides remote consultation but does not physically respond to the emergency
department, he/she is still considered an active care giver and must document his/her
involvement in the medical record.
The minimum criteria for surgeon response to the resuscitation are (1) respiratory
compromise/obstruction and/or intubation (2) penetrating trauma to the abdomen, neck or
chest (3) Glasgow coma scale (GCS) < 8 with a primary etiology attributed to trauma (unless
transfer out is expected to occur within 30 minutes) or (4) two consecutive, pre-hospital systolic
blood pressures less than 90 mmHg in an adult or age-specific hypotension in children as
follows:
Age
mmHg
6 years +
90
2-5 years
80
12-24 months
75
0-12 months
70
1
The consultation may be intermittent.
50
Program Component
Level
III
Level
IV
Criteria Description
Exemption Clause
Surgeon response to the resuscitation is not required if:
 The emergency department is staffed 24 hours/day, 7 days/week by an in-house physician
and
 The emergency department physician determines that the facility resources cannot provide
definitive care and, subsequently, the patient will be emergently
transferred and
 The patient’s length of stay in the emergency department does not exceed
30 minutes.
A hospital utilizing this exemption clause must monitor the practice by use of a PI audit filter.2, 3
The highest-level trauma activation criteria must include (1) respiratory distress, airway
obstruction or intubation; (2) penetrating trauma to neck or torso; (3) Glasgow Coma Scale
(GCS) score ≤8 from an etiology attributed to trauma; (4) evidence of shock indicated by two or
more of the following:
 Heart rate >120 (or age-specific tachycardia in pediatrics)
Age-Specific
Tachycardia
 Systolic blood pressure <90 mmHg (pediatric: 70 + [2 x age in years]
Age
HR
mmHg)
2-5
yr.
>160
 Peripheral hypoperfusion (capillary refill >2 seconds, pallor)
< 2 yr.
>180
 Confusion
 Tachypnea;
and (5) discretion of the emergency department provider (for those patients not meeting any of
the above criteria)
2
Under the exemption clause, the surgeon must respond if:

The emergency department physician determines that the patient will be admitted or

The emergency department physician is uncertain as to whether or not the patient will be admitted or

The emergency department physician requests the surgeon to respond or

The emergency department physician knows or suspects that the patient's length of stay in the emergency department will exceed 30 minutes,
regardless of whether or not a transfer has been initiated (e.g. waiting for a helicopter).
3
A hospital utilizing the Exemption Clause must possess all of the capabilities and resources of a level III trauma hospital. The Exemption Clause only provides
for an exemption to the deployment of the surgeon on a case-by-case basis.
51
Program Component
Level
III
Level
IV
Trauma Program Medical
Director
E
D
Trauma Program Medical
Advisor
NA
E
E
D
NA
E
Trauma Program
Coordinator/Manager
Criteria Description
Trauma program medical director shall be a board-certified or boards-in-progress physician with
special interest in trauma care. Trauma hospitals shall have a physician on staff whose job description
defines his/her role and responsibilities for trauma patient care, trauma team formation,
supervision/leadership, and trauma training/continuing education and acts as the medical staff liaison
for trauma care with out-of-hospital medical directors, nursing staff, administration, and higher level
trauma hospitals. The trauma hospital medical director shall have successfully completed ATLS®
and/or CALS (including the Benchmark Lab or Trauma Module Course) within the last four years.4
The medical director must re-take his/her ATLS or CALS before or during the month in which it
expires.5
Trauma program medical advisor shall be a physician on staff whose job description defines his/her
role and responsibilities for trauma patient care, trauma team formation, supervision/leadership, and
trauma training/continuing education and acts as the medical staff liaison for trauma care with out-of­
hospital medical directors, nursing staff, administration, and higher level trauma hospitals. The
trauma hospital medical advisor shall have successfully completed ATLS® and/or CALS (including
the Benchmark Lab or Trauma Module Course) within the last four years.4 The medical advisor must
re-take his/her ATLS or CALS before or during the month in which it expires.5
This person shall be a RN with clinical experience in trauma care. Alternatively, other qualified allied
health personnel with clinical experience in trauma care may be appropriate. It is expected that the
Coordinator/Manager has allocated time for the trauma program.
This individual shall work in conjunction with the medical director/advisor, helping to organize and
coordinate the facilities’ trauma care response. Ideally this individual should be a RN with
emergency/trauma care experience. Alternatively, other allied health personnel with clinical
experience in emergency/trauma care may fulfill this role.
4
For the initial designation only, hospitals may become designated after the medical providers successfully complete the CALS Provider Course only. They must then
complete the Benchmark Lab or Trauma Module Course within one year of the Provider Course.
5
There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.
52
Clinical Capabilities
Program Component
Level
III
Level
IV
Criteria Description
The operating room must be readily available for trauma care 24 hours/day.
Local criteria may be established to allow the general surgeon to take call from outside the facility,
but with clear commitment on the part of the facility and the surgical staff that the general surgeon
will be available to the ED physician for consultation to assist in the decision for need of surgical
interventions or transfer 24 hours/day. General surgeon response to the resuscitation is required if the
patient meets the minimum criteria for surgeon response or is otherwise required by hospital policy.
General Surgery
E
D
E
E
E
D
NA
E
E
NA
Emergency Medicine
Anesthesia
Eighty (80) percent of the time the general surgeon response to the resuscitation should be within 30
minutes of the patient’s arrival in the emergency department meet the response time
requirements of the trauma system.
The surgeon must also be available to care for trauma patients in the ICU. Compliance with this
requirement and applicable criteria must be monitored by the trauma PI program.
A formal plan must be in place indicating:
 How the trauma patient will be managed should the usual surgical coverage be temporarily
unavailable for any reason (e.g., the surgeon is already in surgery)
 How surgeon call will be covered when scheduled gaps in the usual coverage occur (e.g.,
vacations)
Surgeon must be present at all operative procedures performed in the operating room.
Published and posted call schedules must specifically identify the physician/provider on call for the
emergency department.
24-hour coverage by a physician who is present at all emergency resuscitations. If the physician is
off-site, his/her response to the hospital should be within 15 minutes of EMS notification. (See
“Clinical Qualifications for further emergency physician details.)
Physician assistants (PA) and/or nurse practitioners (NP) may provide lead coverage in the emergency
department. They must be present at the resuscitation. 24-hour coverage must be provided. If the ED
provider is off-site, his/her response to the hospital should be within 30 minutes of EMS notification.
(See Clinical Qualifications for further Other Medical Staff Covering Emergencies.)
When the lead emergency department provider is a mid-level practitioner (NP or PA), a physician
who meets the training standards of the System must be on call and available to the mid-level
practitioner to consult by telephone (or similar means) within 30 minutes.
May be covered by certified registered nurse anesthetist (CRNA).
53
Program Component
Level
III
Level
IV
Orthopedic Surgery
E
NA
Post Anesthesia Recovery
E
NA
E
D
E
NA
E
NA
E
E
E
NA
Radiology
Respiratory Therapy
Clinical Laboratory
Criteria Description
The ED physician, in consultation with the general surgeon, makes critical trauma care decisions in
the emergency department. There is no expectation that an orthopedic surgeon be onsite or
immediately available.
While orthopedic surgical capabilities will vary among Level IIIs, it is an expectation that all Level
IIIs be able to handle basic orthopedic surgical cases. It is the responsibility of the Level IIIs to have
protocols that clearly define which cases they can handle and which cases require transfer to an
appropriate facility.
If necessary, the same individual may cover both general surgery and orthopedic surgery if he/she
meets the clinical qualifications for each discipline.
RN available 24 hours/day
24-hour radiologist coverage required (may utilize in-house, on-call or teleradiology resources).
Radiology technician available or on-call 24 hours/day
24-hour availability of computed tomography
In-house or on-call 24-hour coverage. A nurse with specific in-house ventilator training may provide
this coverage. Records of in-house CEUs must be maintained.
Must have a comprehensive blood bank or access to community blood bank.
24-hour availability of a laboratory capable of standard analysis of blood, urine and other body fluids,
including micro sampling
24-hour availability of a laboratory capable of:
 Blood typing and cross matching
 Coagulation studies
 Blood gas and ph determination
 Microbiology
54
Program Component
Level
III
Level
IV
Criteria Description
An age-specific, pre-determined, pre-written plan/protocol/flow chart that directs the internal process
for rapidly and efficiently transferring a trauma patient to definitive care. The plan should address
such things as: appropriate ground and air transport services, along with contact numbers and backup
providers; and what supplies, records, personnel and/or other necessary resources will accompany the
patient. Must also clearly identify the anatomical and physiological criteria that, if met, will
immediately initiate transfer to definitive care.
Designated trauma hospitals may not transfer adult or pediatric patients to undesignated hospitals.
Exception: Patients may be transferred to a Veterans Administration Medical Center.
Trauma Transfer
E
E
When a trauma patient is transferred to designated trauma hospital in another state, the sending
hospital must attempt to obtain information related to the final disposition of the patient, particularly
whether or not the patient required another transfer from the receiving hospital for definitive care.
The hospital must have the following transfer agreements with facilities capable of caring for major
trauma patients:
 Hemodialysis
 Burn care
 Acute spinal cord injury
In the case of burn care, a second agreement is necessary in the event the primary burn facility lacks
the capacity to receive the patient. A comprehensive transfer agreement with a level I or II trauma
hospital may suffice if that trauma hospital has the required capabilities.
55
Clinical Qualifications
Program Component
Level
III
Level
IV
Criteria Description
If currently board certified in general surgery, then required to only have successfully completed an
Advanced Trauma Life Support (ATLS®) or Comprehensive Advanced Life Support (CALS) course
(including Benchmark Lab or Trauma Module Course) once.
If not board certified in general surgery, then must have successfully completed ATLS® and/or CALS
(including the Benchmark Lab or Trauma Module Course) within the last four years.6 Surgeons must
re-take their ATLS or CALS before or during the month in which it expires.7
General Surgeon
E
D
Physicians who are board-certified in pediatric surgery and practicing in a pediatric hospital are
required only to have successfully completed an ATLS® or CALS course (including Benchmark Lab
or Trauma Module Course) once.
Effective January 1, 2015, must have successfully completed ATLS® and/or CALS (including
the Benchmark Lab or Trauma Module Course) within the last four years.6 Providers must re­
take their ATLS or CALS before or during the month in which it expires.7
If currently board certified with an American Board of Emergency Medicine (ABEM)-approved or
American Osteopathic Board of Emergency Medicine (AOBEM) certification, then required to only
have successfully completed an ATLS® or CALS course (including Benchmark Lab or Trauma
Module Course) once.
Emergency Physician
E
E
If not board certified with an ABEM-approved or AOBEM certification, then must have successfully
completed ATLS® and/or CALS (including the Benchmark Lab or Trauma Module Course) within
the last four years.5, Emergency physicians must re-take their ATLS or CALS before or during the
month in which it expires.6
Effective January 1, 2015 physicians scheduled to work in the emergency department as a second
provider must meet the training requirements of the trauma system.
6
For the initial designation only, hospitals may become designated after the medical providers successfully complete the CALS Provider Course only. They must then
complete the Benchmark Lab or Trauma Module Course within one year of the Provider Course.
7
There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.
56
Program Component
Other Medical Staff
Covering Emergencies
(e.g., NPs, PAs, Locum
Tenens)
Orthopedic Surgeon
Registered Nurse Trauma
Education
Level
III
Level
IV
E
E
E
E
D
D
E
E
Criteria Description
Must have successfully completed ATLS® and/or CALS (including the Benchmark Lab or Trauma
Module Course) within the last four years.8, Providers must re-take their ATLS or CALS before or
during the month in which it expires.9 This requirement is for those who are regularly scheduled in the
emergency department. It does not apply to those who are called in to back-up the attending physician
during an unusual and rare event. (See Performance Improvement section.)
Effective January 1, 2015 physicians and physician extenders scheduled to work in the emergency
department as a second provider must meet the training requirements of the trauma system.
May be a surgeon with the ability to do orthopedic surgery and who is credentialed by the hospital to
do so. (Note: This is “Essential” for Level IV facilities ONLY if orthopedic surgical services are
provided).
Successfully complete an ATLS® or CALS course.
Registered nurses responsible for emergency and/or critical care setting (i.e., ICU) must have successfully
completed appropriate professional trauma education. (Example: Trauma Nursing Core Course (TNCC),
Comprehensive Advanced Life Support (CALS) Provider Course, Advanced Trauma Care for Nurses
(ATCN), Course in Advanced Trauma Nursing (CATN), or in-house training10 that meets the following
objectives:
 Identify the common mechanisms of injury associated with blunt and penetrating trauma.
 Describe and demonstrate the components of the primary and secondary nursing assessment of the
trauma patient.
 List appropriate interventions, based on the assessment findings, for recognized and suspected
life-threatening and non-life-threatening injuries.
 Correlate signs and symptoms to specific pathophysiological changes as it they relate to potential
injuries.
 Describe the ongoing assessment and methods used to evaluate the effectiveness of the
interventions.
 Examine the facility's specific criteria and protocols for admission or transfer of the trauma
patient.
8
For the initial designation only, hospitals may become designated after the medical providers successfully complete the CALS Provider Course only. They must then
complete the Benchmark Lab or Trauma Module Course within one year of the Provider Course.
9
There is no grace period for either ATLS or CALS training. The CALS lab component must, too, be re-taken before or during the month in which it expires.
10
Contact the designation coordinator to have in-house curriculum approved before beginning any training. In-house training may be attended concurrently by both RNs and LPNs. 57
Program Component
Licensed Practical Nurse
Trauma Education
11
Level
III
E
Level
IV
E
Criteria Description
Licensed practical nurses that care for patients in the emergency and/or critical care setting (i.e., ICU) must
have successfully completed appropriate trauma education. (Example: Comprehensive Advanced Life
Support (CALS) Provider Course, Rural Trauma Team Development Course (RTTDC), audit of a Trauma
Nursing Core Course (TNCC), audit of a Course in Advanced Trauma Nursing (CATN), or in-house
training11 that meets the following objectives:
 Identify the common mechanisms of injury associated with blunt and penetrating trauma.
 Recognize common signs and symptoms of potentially life-threatening and non-life-threatening
injuries.
 Identify data needed for the ongoing monitoring of a trauma patient.
 Demonstrate role-specific trauma care competencies.
 Examine the role-specific practice parameters for trauma care as defined by the hospital.
 Examine the facility's specific criteria and protocols for admission or transfer of the trauma
patient.
Contact the designation coordinator to have in-house curriculum approved before beginning any training. In-house training may be attended concurrently by both RNs and LPNs.
58
Performance improvement
Program Component
Performance Improvement
Program
Level
III
Level
IV
E
NA
E
E
Criteria Description
General surgeon representation and participation in case reviews and at the trauma performance
improvement (PI), peer review and multidisciplinary committees.
The PI process should review all cases when medical providers who do not normally provide
emergency department coverage are called in to back-up the attending physician during a rare and
unusual event.
The trauma PI program shall be consistent with medical staff and facility policies. All trauma
hospitals shall work with the MDH in statewide PI activities
The PI process may be performed by the trauma hospital’s trauma committee or by an appropriate PI
standing committee.
If teleradiology is utilized, this process shall be monitored and evaluated by the trauma PI program.
Trauma hospitals shall have a formal, trauma-related diversion policy and a mechanism established to
review times and reasons for trauma-related diversion.
The trauma PI program shall consist of a formal policy that includes a minimum of the following:
1. Defined population of trauma patients to be monitored
2. Set of indicators/audit filters to include:
a. General surgeon non-compliance to on-call response times (level 3 only; both physical and
telephone response requirements)
b. General surgeon consulted by phone for highest level trauma activation and did not
write a note in the medical record (level 3 only)
c. Emergency department provider non-compliance to on-call response times
d. Trauma care provided by physicians who do not meet minimal educational requirements, i.e.,
ATLS® or CALS
e. Length of stay >60 minutes before transfer for highest level trauma activation (level 3
only)
f. Patient met trauma transfer criteria and admitted locally
g. All trauma deaths
h. Trauma patients admitted by a non-surgeon
i. Trauma patients transferred out
j. Trauma patients received via transfer
3. Frequency of review
4. Multidisciplinary physician involvement
5. Standard of care
6. Demonstration of loop closure and resolution
59
Program Component
Level
III
Level
IV
Criteria Description
The overall responsibility of concurrent and retrospective review of the care of trauma patients lies
with the trauma program medical director/advisor and the trauma program coordinator/manager in
conjunction with the trauma PI committee and the physician multidisciplinary peer review committee.
Performance Improvement
Program
NA
E
Morbidity And Mortality
Review
E
E
Multidisciplinary Trauma
Review
E
D
Trauma Registry
E
E
Regional Trauma
Advisory Committee
D
D
The trauma program medical advisor or designee (who must meet the training standards of the
System) must review trauma cases attended by an NP or PA within the 72 hours following the
resuscitation.
A mechanism shall be established by which all physicians caring for trauma patients are involved in
confidential peer review of the care in accordance with facility and medical staff policy. These
physicians will regularly review and discuss:
 Results of trauma peer review activities.
 Problematic cases including complications.
 All trauma deaths, identifying each death as non-preventable, possibly preventable, or
preventable.*
The peer review process and minutes of this committee should be confidential and in accordance with
facility and medical staff policy. Utilization of trauma registry data will facilitate the entire PI and
peer review process.
*The STAC has adopted standardized definitions based on industry standards. See the Trauma
Hospital Resource Manual.
Must have an established mechanism by which all those involved in caring for trauma patients are
involved in a review of the care. In addition to attendance by emergency, surgery, anesthesia,
radiology and ICU staff; administration, nursing, radiology, lab, anesthesia and other ancillary
personnel might attend.
Collect trauma data using either the state Web-based system or an in-house program and submit the
required data to the statewide trauma system within 60 days of the patients’ discharge or transfer.
The trauma hospital should actively participate in at least one Minnesota Regional Trauma Advisory
Committee (RTAC) or subcommittee of a Minnesota RTAC.
Active participation is defined as attending at least 50% of the scheduled meetings.
Prevention
Injury Prevention
Activities
E
D
Coordination and/or participation in community prevention activities
60
Equipment Capabilities
Equipment must be available in sizes to care for all ages of trauma patients.
Emergency Department
Airway control and ventilation equipment
Pulse oximetry
Suction devices
Electrocardiograph/oscilloscope/defibrillator
Standard IV fluids and administration sets
Large bore IV catheters
Drugs necessary for emergency care
Nasal gastric & oral gastric tubes
Spine immobilization boards and C-collars
Pediatric length-based resuscitation tape
Thermal control for patient and fluids/blood
Rapid infuser system
End-tidal CO2 detector
Communications with EMS
Mechanism for IV flow-rate control
Intraosseous administration sets
Supplies for surgical airway & thoracostomy
Central lines
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
D
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
NA
E
E
E
E
D
NA
E
E
E
D
D
D
E
E
D
NA
May use pressure bag
May be disposable
Operating Room
Thermal control for patient and fluids/blood
X-ray capabilities including C-arm intensifier
Rapid infuser system
Essential for Level IV only if operating room is available
May use pressure bag
Post Anesthesia Recovery
Equipment for monitoring and resuscitation
Pulse oximetry
Thermal control for patients and fluids/blood
Intensive Care Unit
Equipment for monitoring and resuscitation
Ventilator
Transport ventilator is not sufficient
61
Appendix E: Length of Stays
Trauma Patient Length of Stay before Transfer July 1, 2010 – June 30, 2012 Level 3 Hospitals Only
All trauma transfers
700
620
600
30" or less
500
30"‐60"
400
262
300
60"‐90"
340
305
255
215
120"‐180"
200
100
90"‐120"
180"‐240"
97
>240"
0
1
TTAs only (all tiers)
140
125
120
120
103
30" or less
100
80
30"‐60"
65
60"‐90"
70
90"‐120"
54
60
36
40
120"‐180"
180"‐240"
>240"
20
0
1
62