Region III Trauma Plan July 2016

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1 REGION III RTAC Region III Trauma Plan July 2016 Bill Kunkle 7/14/2016

2 Table of Contents Mission... 2 Vision... 2 Authority... 2 Region Board... 3 Bylaws... 4 Regional Demographics... 4 Injury Epidemiology... 7 Prevention and Education... 7 EMS... 8 Air Medical Trauma Care Protocols and Medical Direction Patient Triage and Destination Determination Method of Transport Determination Educational and Training Standards Definitive Care Facilities Trauma Centers Specialty Resource Centers Pediatrics System Flow Rehabilitation Communications Disaster Preparedness Evaluation and Improvement Research Appendix Appendix A Appendix B

3 Mission To promote, develop, maintain, and further a comprehensive EMS, trauma and acute care system that will meet the needs of all patients through fact based analysis and improvement methods. Vision To provide a comprehensive and unified trauma system that provides top level care for the community and serves as a leader for the State of Georgia. Authority In 2007, Senate Bill 60 was passed by the Georgia Legislature creating the Georgia Trauma Commission. This bill authorized the newly created commission to create a trauma system for Georgia and to be accountable and distribute funds provided by the state for the purpose of improved trauma care. In 2009 the Georgia Trauma Commission approved a strategic plan providing guidance for the future of trauma care in the state. An aspect of this plan was to create Regional Trauma Councils to coincide with the State EMS Regions. Noting that each region of the state is different in their capabilities and needs, each region was tasked with creating their respective RTACS. Each RTAC is then assigned the task of completing a trauma plan. This plan begins with an assessment of the needs of the region, followed by the creation of the document. The plan should then be written following guidance given by the Regional Trauma System Planning Framework document approved by the Trauma Commission in October of The plan should be approved at the local level then presented to the Georgia Trauma Commission for final approval. Following this go ahead, the final plan should be used as a template for improving trauma care within the region. 2

4 Region Board The system leadership is tasked with the responsibility of improving trauma management within Region III. The Region Board and Committee Chair Positions will consist of the following positions and the respective person for each position. Board of Directors Chair Vice Chair Historian Treasurer RTAC Coordinator Committee Air Medical EMS Pediatrics Prevention and Education Disaster Preparedness System Performance Improvement Trauma Center Rehabilitation Officer Dr. Jeffrey Nicholas Dr. Barry Renz Dr. John Harvey Greg Pereira Billy Kunkle Committee Chair Jim Sargent & Dr Isakov Lee Oliver Dewayne Joy Elizabeth Williams Gina Solomon Gina Solomon 3

5 Bylaws The organization s operations shall be governed utilizing by laws approved by the general membership. Regional Demographics Region 3 is composed of eight counties to include the City of Atlanta and the Metro Atlanta area. These eight counties consist of just four percent of the landmass for the State of Georgia, but account for thirty nine percent of the population. The population of this region exceeds the population of 24 of the 50 states. County Square Miles Population Clayton ,542 Cobb ,981 Dekalb ,161 Douglas ,776 Fulton ,319 Gwinnett ,922 Newton ,675 Rockdale ,754 Region III Total 2,309 3,925,130 Percentage of Georgia 4% 39% Georgia 57,513 10,097,343 4

6 Atlanta, known by many as the capital of the south is a financial, tourist, and travel hub for the southeastern United States. The many facets of this region make it a destination point of people from all round the globe. The Hartsfield Jackson Airport is the busiest in the world. This 4,700 acre complex is home to Delta Airlines. In 2014 the airport saw over 860,000 aircraft operations and serviced 96 million passengers. The airport is the largest employment venue in the state offering jobs to more than 55,000 people. There are several additional regional airports as well as Dobbins Air Reserve Base. As a financial leader, 7 of the Fortune 100 companies have their headquarters in Atlanta. In addition to Delta there is also Coca Cola, Home Depot, United Parcel Service, AT&T and Newell Rubbermaid. These companies and the many other industries keep the residents of Region III during the workday and also attract individuals from other regions providing for a higher workday population. 5

7 APPROVED by GTC August 18, 2016 Entertainment also draws large crowds into the Region. The Atlanta Braves, Falcons, Hawks and the Georgia Tech Yellow Jackets all call this region home. In addition Atlanta hosts other large venues such as the NCAA basketball finals, and the Chick Fil A Bowl. The Atlanta Dome, Turner Stadium, and Phillips Arena all provide for these events as well as others such as concerts and other mass gatherings. Additional crowds of people are drawn to entertainment venues such as Six Flags over Georgia, Whitewater Water Park, and Stone Mountain. 6

8 Injury Epidemiology The Region III RTAC Board of Directors and membership have made a commitment to acquire meaningful data to provide information for decision making utilizing the state trauma registry, GEMSIS, T-QIP and other various resources. The board will benchmark these statistics against other areas of the nation with similar demographics and will publish the results annually for the benefit of its membership, community stakeholders, and the general public. Prevention and Education Traumatic injuries of all mechanisms collectively have a significant impact on the public health of our community. Therefor the trauma system should grasp the role of injury prevention as a part of the complete trauma system. The trauma council will utilize data collected by the trauma system to develop evidence based programs in an attempt to reduce the impact of trauma on the residents and transients of Region III and beyond. The programs developed will look to make changes that can prove to have measurable outcomes. A prevention and education council will be established within the RTAC whose role will be charged with leading these initiatives with the backing of the various level care providers in the region. This position should also work with the various stakeholders in the region to include industry, healthcare providers, the media, and the general public to advance this program. 7

9 . EMS This section of the Region III Trauma Plan will consider the pre-hospital portion of trauma care. Pre-hospital providers are often times the first providers of care and have a tremendous impact on patient outcomes based upon indicators such as response time, care provided, and transport to the most appropriate facility. In this the prehospital portion of this trauma plan will consider the following: 1. Pre-hospital resources available in Region III 2. Considerations for resources outside of Region III to be utilized during times of need. 3. Establishing common tenets for protocols of trauma care within the region based upon mutual understanding between the care providers, the medical directors, and the trauma centers. 4. Identify best practices for destination determination for the transport of the trauma patient within Region III. 5. Develop guidelines for the determination of transportation type within the region. 6. Considerations for the dispatch protocols for emergency services. 7. Identify training standards for the 911 provider. 8

10 Georgia s Region III is the most populace region in the state and easily outnumbers many other states based upon considerations such as: 1. Annual EMS responses 2. Trained emergency medical responders 3. Response vehicles The Region consists of the following counties and their respective emergency service providers. Clayton Clayton County Fire and Emergency Services 7810 Highway 85 Riverdale, GA Forest Park Department of Fire and Emergency Services 4539 Jonesboro Rd Forest Park, GA Morrow Fire Department 1500 Morrow Road Morrow, GA Cobb Metro Atlanta Ambulance Service Puckett EMS 595 Armstrong Street 3760 Tramore Point Marietta, GA Austell, GA Douglas Douglas County Fire Department 6856 West Broad Street Douglasville, GA

11 Dekalb Dekalb County Fire and Rescue AMR 1950 W Exchange Place 1380-D Beverage Drive Tucker GA Stone Mountain GA Fulton Atlanta Fire Department Grady EMS Office of Airport Operations 745 Memorial Drive SE 720 Doug Davis Drive Atlanta GA Hapeville, GA Hapeville Fire Department Rural Metro of Georgia 3468 North Fulton Avenue 250 Hembree Park Drive Suite 112 Hapeville, GA Roswell, GA

12 Gwinnett Gwinnett County Fire and Emergency Services 75 Langley Drive Lawrenceville, GA Newton Newton County EMS 5126 Hospital Drive NE Covington, GA Rockdale National EMS 1060 Culpepper Drive Conyers Ga

13 In addition to the licensed 911 providers, Region III has a multitude of responders who routinely respond to calls for help within the region. A comprehensive listing of these agencies would be difficult to list and maintain, however a few services need to be mentioned for their specialty services. Pediatrics Children s Healthcare of Atlanta Transport Services 1405 Clifton Rd Atlanta, GA Air Medical Air Evac Lifeteam Emergency Dispatch AirLife GA 1035 South Hill Street Griffin, GA Emergency Dispatch:

14 Trauma Care Protocols and Medical Direction The 2009 ACS study of the Georgia Trauma System recommends The EMS system medical director must have statutory authority to develop protocols must work closely with the trauma system medical director to ensure that that protocols and goals are mutually aligned...must also have interaction with EMS agency medical directors as local levels The State OEMS&T does maintain a set of treatment protocols that are updated on a regular basis as needed. Region III has a great deal of diversity. There are high rise urban areas within a few minutes of trauma centers, peach orchards in our more rural areas that are an hour from such care, and then the sub-urbans, somewhere in between. Due to this diversity, and Georgia Code allowing for local rule, each EMS agency has their respective treatment protocols. There have been several past attempts to move to a one size fits all approach to place at least the Metro Atlanta agencies on a standardized protocol system. These attempts have failed due to the reasons noted above. To then work within this framework, it will be imperative that EMS directors, the local medical directors, and the trauma center directors come together to establish identified best practice tenets in their respective local protocols. These standards should be evidence based and reviewed on a regular basis to keep maintain currency for best practices. In this same discussion can be brought up the topic of medical direction. Again each agency maintains their own medical director who develops their specific protocols and policies and procedures based upon local rule. In this system, communication between the physicians at each level could resolve and prevent future problems and ultimately lead to better patient care. The Region III RTAC will facilitate such discussions on an annual basis to ensure that the right information is getting to the medical directors of each agency. 13

15 Patient Triage and Destination Determination It is well noted in literature and studies the benefits of transporting the EMS patient to the right facility the first time. This has become even more so with the specialization of medical centers such as cardiac and stroke care. Correct decision making in the transport of the trauma patient is essential to ensure timely and accurate care. The State Trauma Commission has identified and published Georgia Trauma System Primary Triage Decision Scheme (Appendix A) based largely on the National Trauma Triage Protocol of the US Department of Health and Human Services. This set of guidelines utilizes four assessment steps (physiology, anatomy, mechanism of injury, and special considerations) to assist the provider in determining the most appropriate facility to transport the patient to. Region III has accepted this guideline as a best practice for the transport of the trauma patient and will monitor transported patients to be reported as part of the CQI process. Method of Transport Determination Few topics in EMS have drawn as much attention as the need for use of medical aircraft. The most comprehensive study to date completed by the University of Rochester shows that patients transported by air, although not as critical as those transported by ground services, fare better than those transported by ground EMS. (Boynton, 2011) With this information though also comes the desire to do what is best for the trauma patient. Air medical transport, with its benefits, also comes at a significant transportation cost. Knowing this the practitioner should make decisions with the best use of information available such as: 1. Patient needs a. Surgical b. Neurological c. Specialty such as pediatrics or burns d. Advanced airway management 2. Time a. Time for arrival of air medical 14

16 b. Time of transport to a trauma center by air vs by ground c. Access time for patient i. Entrapped ii. Stranded away from ground transport units Noting that this resource is utilized for patients with significant illness or injury, and that time is a significant factor, consideration for air medical transport should occur as early as possible. Protocols should be in place to allow for either the emergency dispatcher or the responding units to request air medical response as part of the initial response and prior to arrival of first responders. This consideration is no different than the response of other emergency resources that may later be cancelled if not needed. Due to the potential of severity of the patient, the cost of utilization of this resource and the relative infrequency of its use, it is recommended that every chart for a patient flown undergo a CQI review by the EMS agency. Educational and Training Standards The ACS assessment of the state reported: It is critical that trauma system leaders work to ensure that prehospital care providers at all levels attain and maintain competence in trauma care. Maintenance of competence should be ensured by requiring standards for credentialing and certification and specifying continuing educational requirements for all prehospital personnel involved in trauma care. The state requires that each prehospital care provider receive 40 hours of training every recertification cycle (2 years) of which 4 hours must be dedicated to trauma. The RTAC will support this and encourage additional training by working together to provide educational opportunities such a PHTLS, ABLS, and pediatric trauma. As part of the CQI process, medical directors, service managers, and trauma team staff should look for recurring disparities in trauma care that might indicate a need for additional education. Trauma leaders should also consider emerging treatment modalities that should be taught to the target audience. With the current abilities of modern technology, reaching the masses of pre-hospital care providers is easier than ever before. The RTAC will look to take advantage of these abilities to 15

17 educate the pre-hospital provider for the betterment of the treatment for patients we serve. The RTAC will also assist with, as able and appropriate, the delivery of Trauma Nurse Core Course (TNCC) and Advanced Trauma Life Support (ATLS). These two courses provide the educational backbone of care within the trauma system Keeping the staff educated and informed will provide great dividends to the trauma patient by ensuring the most up to date and comprehensive knowledge base. Definitive Care Facilities Trauma Centers Region III has a total of 7 designated trauma centers within its boundaries. These include three Level 1trauma facilities (one of which is a pediatric) and four Level II facilities (one of which is pediatric). In addition there is a certified burn center. Adult Facility Atlanta Medical Center Grady Memorial Hospital Gwinnett Medical Center North Fulton Hospital WellStar Kennestone Hospital Pediatric Facilities Egleston Children's Healthcare of Atlanta Scottish Rite Children's Healthcare of Atlanta-Level II Burn Facilities Grady Memorial Hospital Joseph M Still Burn Center Level I I II II II I II Certified Burn Center 16

18 The Region III RTAC will complete a needs assessment annually to identify gaps in trauma care in the region and will then work towards resolving these gaps. A facility working towards trauma certification in an identified gap area will be assisted by the RTAC in working towards their goal of achieving certification. Facilities undergoing this process will be identified for their trauma care capabilities as in active pursuit on the trauma plan and in the region. Specialty Resource Centers Specialty Resource Centers such as pediatric facilities and burn centers provide care above and beyond for certain demographics of trauma patients. They should be utilized as followed. Pediatrics All pediatrics meeting Georgia Trauma System Entry Criteria (Appendix A) should be transported to a pediatric trauma facility. For the purpose of the trauma patient in Region III, a pediatric is defined as age 14 and below. At the time of this writing the sole provider of pediatric trauma care is Children s Healthcare of Atlanta (CHOA) at either Egleston or Scottish Rite. The EMS provider should call in the patient report to the CHOA Communications Center and identify that they are transporting a trauma patient. The CHOA Communications Team will take into consideration destination choice, distance, and facility surgical abilities to identify the destination facility for the EMS provider. 17

19 System Flow Trauma diversion is defined as routing EMS agencies transporting trauma patients to another facility due to a temporary inability to provide adequate trauma care. Each facility is responsible for developing their policy for diversion which should include: 1. Criteria for diversion 2. Person or persons responsible for making diversion decision 3. Method and responsibility of notifying EMS of diversion status 4. Record keeping and performance improvement of diversions status. The RTAC will develop and maintain a memorandum of understanding (MOU) between the RTAC and the trauma centers regarding trauma diversion. This MOU should be developed by the Trauma Center Council and approved by the voting members of the RTAC to be added to this trauma plan at a later date. Patient transfers are also a point of concern for the flow of trauma patients. Patients are frequently transferred from within the region or into the region from areas with no or limited trauma services. The Trauma Center Council should develop a policy to be added to this plan regarding the following criteria: 1. Destination choice a. Distance b. Level of care c. Specialty resource care needed 2. Method of transport a. Air b. Ground 18

20 Rehabilitation Rehabilitation is the process of helping a patient adapt to a disease or disability by teaching them to focus on their existing abilities. Within a rehabilitation center, physical therapy, occupational therapy, and speech therapy can be implemented in a combined effort to increase a person s ability to function optimally within the limitations placed upon them by disease or disability. To uphold the continuum of care from illness to health and offer a high-level of service, rehabilitation is a critical service offered within TSA-E through hospital-based programs and private organizations. Transfer protocols for rehabilitation facilities are determined by individual facilities. Communications In any disaster and during every day operations, communications is a vital aspect of the trauma care system. Due to the diversity of the region, a one size fits all model of communication is not practical and therefore makes communications during large scale events difficult. Also the transition of many agencies to the use of cellular technology creates a dilemma during times of disaster due to the system becoming overwhelmed. The Region III RTAC will be involved in establishing regional communications policies to identify and resolve these and addition communications issues. 19

21 Also in the discussion of communications are the less emergent, but none the less important messages that need to be sent. A great plan is of little use if all of the players do not know what the plan is. It will be incumbent upon the Region III RTAC to distribute trauma plans and policies to the providers of Region III and further as necessary. The RTAC may utilize additional resources such as the EMS Council and the GTCNC website as available. The Region III RTAC will track and ensure that important notices and communications are received by the appropriate individuals at the appropriate facilities. Part of the charge for the RTAC as given by the GTCNC was to address in this plan, connectivity with the Georgia Trauma Communications Center. In 2016, the Trauma Communications ceased operations, therefor this operation is not addressed further. Disaster Preparedness The emergency response system within Region III incorporates all emergency support functions (ESF) indicated in the National Response Framework, and is incorporated within state and local plans. Regional ESF-8 (Health and Medical) response to incidents and emergencies, in which response is localized, is typically managed by individual hospitals, EMS agencies, and with minimal involvement by supporting local health departments and jurisdictional emergency management officials. However, additional regional resources must be used when these incidents exceed local capacity and local jurisdictions are required in order to achieve a satisfactory response. As reflected in the state of Georgia Emergency Operations Plan (GEOP) all emergencies are considered a local responsibility. Therefore legal responsibility for provision of support for emergencies is placed on the senior elected official within the affected jurisdiction. Response entities such as hospitals and EMS agencies must work through these officials when resource needs cannot be met by local assets only. 20

22 Many resources have been placed within Region III by participation in a number of Federal and State programs designed to enhance local and regional ESF-8 readiness. These programs include: - Georgia Regional Hospital Coordinating Program through which area hospitals work together to achieve a more fluid and balanced response to disaster. - Jurisdictional participation through health departments and local emergency preparedness. These programs prepare jurisdictions, their supporting local health departments, and partnering health and medical professional for epidemiological intervention and biological events, including Strategic National Stockpile (SNS) preparations. - Georgia Emergency Management Agency (GEMA) Area 7 Evaluation and Improvement The System Performance Improvement (SPI) Committee reviews aggregate data and specific case reviews in Region III. This review process analyzes the aggregate data generated by sources such as T-QUIP, GEMSIS and the Trauma Registry. The committee is composed of defined members of the RTAC and defines the guidelines and processes for review. The committee will have 2 charges: 1. To consider specific cases for review. An agency may recommend a case for trauma care review where the SPI committee will review each aspect of care and offer fact based recommendations regarding future operations. The SPI Committee can then forward the cases to the Board with recommendations for action. Actions may include a. Refer to Region III Council b. Consider altering existing RTAC policies or creating new to positively affect patient care outcomes. 2. To review data, both individual and aggregate, with the intent to identify process and system changes that will positively affect patient care outcomes. 21

23 a. The SPI committee should identify key performance indicators (KPI) for each discipline of care within the trauma system. These KPI s should be based upon sound scientific and protocol driven criteria. b. These KPI s should be reviewed annually to ensure continued relevance within the trauma system. c. The SPI Committee shall compare the appropriate data with the KPI s regularly and a minimum of on an annual basis. This review will be to assess to operations of agencies and the regional system as a whole. The intent will be to improve care for the trauma patient. The committee should establish key performance indicators for each discipline of care within the trauma system. These KPI s should be based upon sound scientific and protocol driven criteria. The committee will use the information gained to make recommendations for changes in policy. In cases of negligence and continual noncompliance with policy, the SPI committee will advise the Board, who may then choose to refer the issue to the Region III Office of EMS and Trauma. Research The Region III RTAC participates in system research on an ad hoc basis. The Board of Directors is responsible for governance and release of the data. Appendix Appendix A- Georgia Trauma System Primary Triage Decision Scheme Appendix B-Guidelines for Trauma Center Destination 22

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