AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA Trauma Systems Evaluation and Planning Committee

Trauma System Consultation Report State of South Carolina Columbia, South Carolina May 19-22, 2014

A multidisciplinary working group prepared this document based on the consultation visit that took place May 19-22, 2014 in the State of South Carolina and included the following members: Team Leader: Robert J. Winchell, MD, FACS Chair, Trauma Systems Evaluation and Planning Committee American College of Surgeons, Committee on Trauma Associate Professor of Surgery Tufts University School of Medicine Chief, Division of Trauma and Burn Surgery Maine Medical Center Portland, Maine Review Team: Jane Ball, RN, DrPH Technical Advisor TSC American College of Surgeons Director, National Resource Center (EMS-C & Trauma) – Retired Washington, DC Stephen F. Flaherty, MD, FACS Trauma Medical Director Cape Fear Valley Health System Fayetteville, NC Heidi A. Hotz, RN Trauma Program Manager Cedars-Sinai Medical Center Los Angeles, CA Maria Fernanda Jimenez, MD, FACS Hospital Universitario Professor of General Surgery Universidad del Rosario Fergus Laughridge, EMTP Humboldt General Hospital EMS and Rescue Winnemucca, Nevada Kathy J. Rinnert, MD, MPH, FACEP Professor of Emergency Medicine Associate Medical Director Section of Emergency Medical Services University of Texas Southwestern at Dallas Dallas, TX Nels D. Sanddal, REMT-B, CMO, PhD, MS Manager, Trauma Systems and Verification Programs American College of Surgeons Chicago IL ACS Staff: Holly Michaels Program Administrator Trauma Systems Consultation Program

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Table of Contents Executive Summary ....................................................................................................................................... 5 Overview ................................................................................................................................................... 5 Advantages and Assets............................................................................................................................. 6 Challenges and Vulnerabilities .................................................................................................................. 7 General Themes........................................................................................................................................ 8 Priority Recommendations ........................................................................................................................ 9 Trauma System Assessment ....................................................................................................................... 11 Injury Epidemiology ................................................................................................................................. 11 Optimal Elements................................................................................................................................ 12 Current Status ..................................................................................................................................... 13 Recommendations .............................................................................................................................. 14 Indicators as a Tool for System Assessment........................................................................................... 16 Optimal Element ................................................................................................................................. 16 Current Status ..................................................................................................................................... 16 Recommendations .............................................................................................................................. 17 Trauma System Policy Development ........................................................................................................... 18 Statutory Authority and Administrative Rules .......................................................................................... 18 Optimal Elements................................................................................................................................ 18 Current Status ..................................................................................................................................... 19 Recommendations .............................................................................................................................. 20 System Leadership.................................................................................................................................. 21 Optimal Elements................................................................................................................................ 22 Current Status ..................................................................................................................................... 22 Recommendations .............................................................................................................................. 23 Coalition Building and Community Support ............................................................................................. 25 Optimal Element ................................................................................................................................. 25 Current Status ..................................................................................................................................... 26 Recommendations .............................................................................................................................. 27 Lead Agency and Human Resources Within the Lead Agency ............................................................... 29 Optimal Elements................................................................................................................................ 29 Current Status ..................................................................................................................................... 30 Recommendations .............................................................................................................................. 31 Trauma System Plan ............................................................................................................................... 32 Optimal Element ................................................................................................................................. 32 Current Status ..................................................................................................................................... 33 Recommendations .............................................................................................................................. 33 System Integration .................................................................................................................................. 35 Optimal Elements................................................................................................................................ 35 Current Status ..................................................................................................................................... 36 Recommendations .............................................................................................................................. 37 Financing................................................................................................................................................. 38 Optimal Elements................................................................................................................................ 38 Current Status ..................................................................................................................................... 39 Recommendations .............................................................................................................................. 41 Trauma System Assurance ......................................................................................................................... 42 Prevention and Outreach ........................................................................................................................ 42 3

Optimal Elements................................................................................................................................ 42 Current Status ..................................................................................................................................... 43 Recommendations .............................................................................................................................. 45 Emergency Medical Services .................................................................................................................. 47 Optimal Elements................................................................................................................................ 49 Current Status ..................................................................................................................................... 50 Recommendations .............................................................................................................................. 52 Definitive Care Facilities .......................................................................................................................... 53 Optimal Elements................................................................................................................................ 55 Current Status ..................................................................................................................................... 56 Recommendations .............................................................................................................................. 57 System Coordination and Patient Flow ................................................................................................... 58 Optimal Elements................................................................................................................................ 59 Current Status ..................................................................................................................................... 59 Recommendations .............................................................................................................................. 60 Rehabilitation .......................................................................................................................................... 61 Optimal Elements................................................................................................................................ 61 Current Status ..................................................................................................................................... 62 Recommendations .............................................................................................................................. 63 Disaster Preparedness ............................................................................................................................ 64 Optimal Elements................................................................................................................................ 65 Current Status ..................................................................................................................................... 65 Recommendations .............................................................................................................................. 66 Systemwide Evaluation and Quality Assurance ...................................................................................... 67 Optimal Elements................................................................................................................................ 67 Current Status ..................................................................................................................................... 68 Recommendations .............................................................................................................................. 70 Trauma Management Information Systems............................................................................................. 72 Optimal Elements................................................................................................................................ 73 Current Status ..................................................................................................................................... 74 Recommendations .............................................................................................................................. 75 Research ................................................................................................................................................. 76 Optimal Elements................................................................................................................................ 78 Current Status ..................................................................................................................................... 78 Recommendations .............................................................................................................................. 79 Appendix A: Acronyms ................................................................................................................................ 80 Appendix B: Methodology ............................................................................................................................ 82 Appendix C: Review Team Biographical Sketches ...................................................................................... 83 Appendix D: Participant List......................................................................................................................... 88 Appendix E: Trauma Registrar Sample Job Description .............................................................................. 90 Appendix F: Sample List of Statewide PI Indicators .................................................................................... 92

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Executive Summary Overview The state of South Carolina has been engaged in the process of trauma system development since the 1980’s. In the years between 2000 and 2008, the trauma system experienced a period of strong growth as evidenced by:    

the development of public awareness, the passage of enabling legislation, the creation of a lead agency, and the provision of significant funding.

As described by stakeholders, difficulties in implementation, unintended consequences of the financial structures, and erosion of funding levels led to a period of stagnation. The lack of progress over the past 5 years has weakened the trauma system and its stakeholder coalitions. Frequent changes in leadership and key personnel within the lead agency have created a situation in which there is no established long-term plan and no clear sense of future direction. The lead agency is understaffed and struggles to fulfill the most basic maintenance functions, leaving little time for system oversight and quality improvement. The multi-disciplinary Trauma Advisory Council (TAC) has suffered from loss of stakeholder morale and subsequent apathy. It appears to have essentially ceased to function over a several year period. Many of the trauma systemrelated duties of the TAC have been assumed by a strong coalition of trauma center program managers and trauma registrars, the Trauma Association of South Carolina (TASC). At the present time, the South Carolina trauma system functions as a collection of individual level I and level II trauma centers that work cooperatively with each other and with surrounding level III centers and smaller hospitals. However, this collection of trauma centers lacks significant systemwide coordination or oversight. As a result, the system faces significant challenges in the provision of optimal care to the injured patients within the state. Over the past two years, a resurgence of energy and interest in trauma system development has occurred with new leadership within the lead agency and with revitalization and renewed energy within the core stakeholder community. Much of the original framework of the trauma system, including the 1995 trauma plan as well as operational policies and procedures, has been both literally and figuratively lost as a result of personnel turnover. This creates an atmosphere in which change is essential and unavoidable, removing any potential resistance arising from an established status quo. Despite erosion of trauma system funding and a current distribution formula that does not provide sufficient support for the functions of the lead agency, South Carolina has significant resources dedicated to the trauma system. In addition, a dedicated group of providers and stakeholders across the spectrum of care is present. In the balance, 5

the conditions are such that significant short-term progress can be made while efforts are undertaken to improve the broader foundation of the system.

Advantages and Assets The long history of commitment to trauma care and participation in trauma system development that is demonstrated by the facilities and providers across the continuum is a major asset. This combined with public awareness and legislative interest a decade ago led to good enabling legislation and substantial funding for trauma care, which exceeds what exists in most states. The success of the trauma system to date can be measured by the provision of care at a level I or level II trauma center within 60 minutes for 88% of the population and 77% of land area based on 2010 data. This coverage is substantially better in the present system configuration due to the addition of level II trauma centers in the northeastern part of the state. This coverage compares favorably to national averages of 82% for population and 29% of land area. South Carolina faces no major geographical challenges and has few isolated rural areas. The new leadership in the Department of Health and Environmental Control (DHEC) and a new state trauma program manager has provided renewed commitment to trauma system development. This commitment is further enhanced by the assets of renewed stakeholder engagement in the TAC and the ongoing work of the TASC. The South Carolina Hospital Association has been an engaged participant since the initial development of the trauma system, and remains committed to ongoing improvements. The stakeholders expressed a clear perception that change is necessary, and they indicated a shared resolve to begin the process. This is a significant advantage that should help speed early progress. Although funding for the trauma system has eroded over the years, the overall level of funding remains above average on a national basis. In addition, the distribution formula can be modified without a change in the underlying legislation which is a significant advantage that makes it possible to modify the way these funds are utilized. Many areas of strength were found among the individual components that make up the South Carolina trauma system. From a public health perspective, good data are available to evaluate injury epidemiology, and a philosophy already exists to include other time critical illnesses, specifically stroke, into a system-based approach. Additional assets include a very strong program for EMS education, comprehensive medical direction of EMS services, and an excellent EMS data system. Though developed independently of the primary trauma system, statute already requires universal data collection in all hospitals for patients with traumatic brain and spinal cord injury. This is a crucial step that will facilitate setting a standard for universal data collection for all injured patients.

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Challenges and Vulnerabilities South Carolina has suffered from recent instability in trauma system leadership at the DHEC, the loss of key personnel in the trauma program, and the associated loss of institutional memory, vision, and operational processes. For example, the 1995 trauma plan, upon which the trauma system is based, was literally lost, and most of the current system leadership, both at the DHEC and the TAC, has little or no knowledge of its content. As a result, no long term vision or plan for the trauma system exists, and there are few well established procedures for basic functions such as trauma center designation. The lead agency is challenged to manage the day-to-day operational issues and lacks the resources to do the work of planning and process development. Although South Carolina has thus far been spared from significant challenges to the structure of the trauma system or highly contentious policy decisions, these issues are likely to arise at some point in the future. No consistent and transparent processes are in place to make such decisions. The lack of consistent leadership and coherent vision, as well as severe resource limitations, have led to an erosion of stakeholder morale and to the loss of public awareness relative to the early 2000’s, some of which may also be related to the poorly visible place the trauma program occupies in the overall organizational structure of the DHEC. A prior decline in trauma system funding that despite remaining constant over the past several years led to a significant funding challenge, but perhaps even more importantly, the distribution of these existing funds does not foster trauma system stability and improvement. The distribution formula is based upon a twenty-year-old model of trauma system development which distributes over 97.5% of the funds to EMS, health care facilities, and individual providers, with minimal support of necessary resources within the lead agency. This situation exacerbates the drop in the overall level of financial support, and has left the lead agency with insufficient resources to fulfill its role. For example, the timeline for redesignation of trauma centers has not been adhered to, no process for planning and adapting for the future direction of the trauma system has been established, and no organized process for system-wide oversight and quality improvement exists. The trauma center designation process, based on the same outdated model for trauma system development, is weak. The standards for trauma center designation are no longer consistent with current national standards, and standards are not consistently applied across the facilities within the system. Further, no established process to assess population need, and no authority to designate (or decline to designate) new trauma centers based upon that need exists.

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General Themes The original trauma system vision and operational structure are no longer functional, and they are essentially lost. These elements must be completely rebuilt from the ground up. The status quo is not an option, so change is essential and unavoidable. The vision for trauma system development and its operational structure should be based upon the principles of an inclusive trauma system. Central principles include the following:  A trauma system is more than an aggregation of trauma centers.  The inclusion of all acute care facilities does not imply an unregulated system in which the facilities determine their own level of participation.  A robust infrastructure is essential to steward ongoing development of the trauma system according to a shared vision, to maintain system oversight, and to allow for collection and analysis of quality data regarding trauma system performance to enable that oversight. The lead agency and the TAC must renew their vision for the trauma system, develop a trauma plan, and establish clear operational procedures. Even in an era of shrinking budgets, South Carolina has significant resources that can be utilized more efficiently to enable progress in ongoing trauma system development. The process of system development should not be held back by perceived barriers. The process of change should begin immediately.

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Priority Recommendations Statutory Authority 

Seek a legal review of the confidentiality section of the EMS statute (Section 4461-550) and associated regulation (R 61-116, 1004), along with other sections/regulations as needed, to confirm the confidentiality and discoverability protection for peer review to conduct EMS and Trauma Program systemwide performance improvement. o If confidentiality protection is not confirmed, request language to revise and strengthen the EMS statute and the associated regulations so that meaningful systemwide performance improvement can be performed.

System Leadership 

Formalize the structure and operational activities of the Trauma Advisory Council (TAC), including the identification and establishment of a functional executive committee.

Coalition Building and Community Support 

Develop a vision for the South Carolina trauma system to include the roles and responsibilities of the Trauma Advisory Council in implementing this vision. o Use an expert facilitator external to the Division of Emergency Medical Services and Trauma to support this process.

Lead Agency and Human Resources within the Lead Agency 

Hire additional full time staff to support the state Trauma Program Manager to include a state performance improvement coordinator and a state trauma registrar.



Develop a tactical plan to enable the Division of EMS and Trauma to support development of and to operationalize the comprehensive trauma system plan.

Trauma System Plan 

Develop a comprehensive trauma system plan using the authority of the existing enabling legislation. o Review and revise the plan on a scheduled basis, e.g. every 3-5 years.

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

Ensure that the trauma system plan is developed with key elements (see Trauma System Plan section for more detail).

Financing 

Realign the disbursement of the State Trauma Care Fund to provide a larger portion for state trauma system program operations as outlined in the statute.

Definitive Care 

Adopt the designation criteria specified in the most current version of the American College of Surgeons Committee on Trauma (ACS-COT) Resources for the Optimal Care of the Injured Patient.



Consider using the ACS-COT Verification, Review, and Consultation process to optimize resource utilization within the lead agency.



Require all acute care facilities to participate in the inclusive and integrated trauma system as a condition of licensure. o Designate each acute care facility at an appropriate level, either as a trauma center or a participating facility.

Rehabilitation 

Complete a needs assessment and gap analysis of rehabilitation capabilities and capacity across the state.

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Trauma System Assessment Injury Epidemiology Purpose and Rationale Injury epidemiology is concerned with the evaluation of the frequency, rates, and pattern of injury events in a population. Injury pattern refers to the occurrence of injury-related events by time, place, and personal characteristics (for example, demographic factors such as age, race, and sex) and behavior and environmental exposures, and, thus, it provides a relatively simple form of risk- factor assessment. The descriptive epidemiology of injury among the whole jurisdictional population (geographic area served) within a trauma system should be studied and reported. Injury epidemiology provides the data for public health action and becomes an important link between injury prevention and control and trauma system design and development. Within the trauma system, injury epidemiology has an integral role in describing the root causes of injury and identifying patterns of injury so that public health policy and programs can be implemented. Knowledge of a region’s injury epidemiology enables the identification of priorities for directing better allocation of resources, the nature and distribution of injury prevention activities, financing of the system, and health policy initiatives. The epidemiology of injury is obtained by analyzing data from multiple sources. These sources might include vital statistics, hospital administrative discharge databases, and data from emergency medical services (EMS), emergency departments (EDs), and trauma registries. Motor-vehicle crash data might also prove useful, as would data from the criminal justice system focusing on interpersonal conflict. It is important to assess the burden of injury across specific population groups (for example, children, elderly people and ethnic groups) to ensure that specific needs or risk factors are identified. It is critical to assess rates of injury appropriately and, thus, to identify the appropriate denominator (for example, admissions per 100,000 population). Without such a measure, it becomes difficult to provide valid comparisons across geographic regions and over time. To establish injury policy and develop an injury prevention and control plan, the trauma system, in conjunction with the state or regional epidemiologist, should complete a risk assessment and gap analysis using all available data. These data allow for an assessment of the “injury health” of the population (community, state, or region) and will allow for the assessment of whether injury prevention programs are available, accessible, effective, and efficient. An ongoing part of injury epidemiology is public health surveillance. In the case of injury surveillance, the trauma system provides routine and systematic data collection and, along with its partners in public health, uses the data to complete injury analysis, interpretation, and dissemination of the injury information. Public health officials and 11

trauma leaders should use injury surveillance data to describe and monitor injury events and emerging injury trends in their jurisdictions; to identify emerging threats that will call for a reassessment of priorities and/or reallocation of resources; and to assist in the planning, implementation, and evaluation of public health interventions and programs. Optimal Elements I. There is a thorough description of the epidemiology of injury in the system jurisdiction using population-based data and clinical databases. (B-101) a. There is a through description of the epidemiology of injury mortality in the system jurisdiction using population-based data. (I-101.1) b. There is a description of injuries within the trauma system jurisdiction, including the distribution by geographic area, high-risk populations (pediatric, elderly, distinct cultural/ethnic, rural, and others), incidence, prevalence, mechanism, manner, intent, mortality, contributing factors, determinants, morbidity, injury severity (including death), and patient distribution using any or all the following: vital statistics, ED data, EMS data, hospital discharge data, state police data (data from law enforcement agencies), medical examiner data, trauma registry, and other data sources. The description is updated at regular intervals. (I-101.2) Note: Injury severity should be determined through the consistent and systemwide application of one of the existing injury scoring methods, for example, Injury Severity Score (ISS). c. There is comparison of injury mortality using local, regional, statewide, and national data. (I-101.3) d. Collaboration exists among EMS, public health officials, and trauma system leaders to complete injury risk assessments. (I-101.4) e. The trauma system works with EMS and public health agencies to identify special at-risk populations. (I-101.7) II. Collected data are used to evaluate system performance and to develop public policy. (B-205) a. Injury prevention programs use trauma management information system data to develop intervention strategies. (I-205.4) III. The trauma, public health, and emergency preparedness systems are closely linked. (B-208) a. The trauma system and the public health system have established linkages, including programs with an emphasis on population based public health surveillance and evaluation for acute and chronic traumatic injury and injury prevention. (I-208.1)

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IV. The jurisdictional lead agency, in cooperation with the other agencies and organizations, uses analytic tools to monitor the performance of population-based prevention and trauma care services. (B-304) a. The lead agency, along with partner organizations, prepares annual reports on the status on injury prevention and trauma care in the state, regional, or local areas. (I-304.1) b. The trauma system management information system database is available for routine public health surveillance. There is concurrent access to the databases (ED, trauma, prehospital, medical examiner, and public health epidemiology) for the purpose of routine surveillance and monitoring of health status that occurs regularly and is a shared responsibility. (I-304.2) Current Status The Division of Injury and Violence Prevention (DIVP) exists within the Department of Health and Environmental Control (DHEC). This division previously received Core Injury Grant funding for one year from the Centers for Disease Control and Prevention (CDC) that was used to support development and publication of South Carolina Status of Injury Data Report, 2010 and the South Carolina Injury Prevention Plan 2010-2015. Current information is available through these reports that reveal the pattern of injury mortality and morbidity by age group and mechanism of injury for a single year. Benchmarking comparison with national data is provided for leading causes of injury mortality. An overall trend of injury mortality from all causes reveals a downward trend in injury as a cause of overall mortality for South Carolina residents. However, injury trends associated with major injury mechanisms are not included. An additional report also provides a county profile of injury, specifically illustrating injury morbidity and mortality for children and youth as well as elders. A separate report of injury from the statewide trauma registry is available. While valuable in illustrating major injuries requiring hospitalization among designated trauma centers, these data are not population-based and may not reveal the true pattern of severe injuries among South Carolina residents. No data were obtained from trauma centers bordering the state to learn more about additional injured residents needing trauma care. A report of injuries resulting in an emergency medical services (EMS) response and transport was not provided, but data in the prehospital management information system (PreMIS) could be used to produce that report. Some data were reported from the South Carolina Head and Spinal Cord Injury Information System. Numerous data sources were used for the South Carolina Status of Injury Data Report, 2010, including vital records, hospital discharge data, and emergency department discharge data, which provide population-based data. The published reports do not demonstrate evidence of other valuable data sources, such as the Fatality Analysis Reporting System (FARS), law enforcement, medical examiner data, the statewide trauma registry, or the EMS data in PreMIS. No evidence of data linkage is noted in the 13

published reports, such as EMS with the statewide trauma registry, or FARS with the EMS data system. Data linkage between various data systems would be valuable to more fully describe the injury control system from prevention through each level of intervention (e.g., EMS response, trauma care) and resulting outcomes. Such information would help illustrate the importance of the trauma system in saving lives and reducing disabilities for individuals with significant injuries. Plans were described for the future assignment of an existing epidemiologist position to the DIVP who will have responsibility for updating the state’s injury profile and supporting an application for a CDC Core Injury Grant. Funding for this position is potentially available for one year. It was reported that the individual expected to fill the injury epidemiology position does not have specialized training in injury epidemiology. Opportunities for interaction with injury epidemiologists at the CDC and support for learning specialized applications of epidemiology methods for injury analyses are encouraged, such as data linkage, geographic information systems (GIS) mapping, and injury severity score (ISS) mapping of the hospital discharge data. An existing agreement between the DHEC and the University of South Carolina (USC) School of Public Health to enable graduate student internships or fellowships was described. This is a potential resource that could be explored for the preparation of future injury epidemiology reports. Recommendations 

Identify additional data systems or resources within state agencies that may contribute to the understanding of injury mechanisms, such as the Fatality Analysis Reporting System, motor vehicle moving violations, and medical examiner data. o Seek agreements to access the databases for injury epidemiology reports.



Encourage the individual filling the epidemiologist position in the Division of Injury and Violence Prevention to interact with Centers for Disease Control and Prevention injury epidemiology experts or other resources (e.g. the University of South Carolina School of Public Health, Safe States, Children’s Safety Network) for mentoring. o Identify and support the epidemiologist to learn specialized injury epidemiology applications such as data linkage, Geographic Information Systems mapping, and Injury Severity Score (ISS) mapping of hospital discharge data*



Develop a data analysis template and report format to produce a populationbased comprehensive description of severe injuries and treatment patterns using the hospital discharge data.

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o Collect examples of comprehensive state injury epidemiology reports from other states to use as models. o Ensure that the data analysis template and the instructions for data analysis and report preparation are maintained and available for use by future state injury epidemiologists. 

Ensure that injury fact sheets and reports are easily accessible through the state’s website.

*See Trauma Centers in the United States, by Charles C. Branas; Ellen J. MacKenzie; Justin C. Williams; et al., JAMA. 2005;293(21):2626-2633 (doi:10.1001/jama.293.21.2626) for an example of how ISS mapping is used.

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Indicators as a Tool for System Assessment Purpose and Rationale In the absence of validated national benchmarks, or norms, the benchmarks, indicators and scoring (BIS) process included in the Health Resources and Services Administration’s Model Trauma System Planning and Evaluation document provides a tool for each trauma system to define its system-specific health status benchmarks and performance indicators and to use a variety of community health and public health interventions to improve the community’s health status. The tool also addresses reducing the burden of injury as a community-wide public health problem, not strictly as a trauma patient care issue. This BIS tool provides the instrument and process for a relatively objective state and substate (regional) trauma system self-assessment. The BIS process allows for the use of state, regional, and local data and assets to drive consensus responses to the BIS. It is essential that the BIS process be completed by a multidisciplinary stakeholder group, most often the equivalent of a state trauma advisory committee. The BIS process can help focus the discussion on various system strengths and weaknesses, can be used to set goals or benchmarks, and provides the opportunity to target often limited resources and energies to the areas identified as most critical during the consensus process. The BIS process is useful to develop a snapshot of any given system at a moment in time. However, its true usefulness is in repeated assessments that reveal progress toward achieving various benchmarks identified in the previous application of the BIS. This process further permits the trauma system to refine goals to be attained before future reassessments using the tool. Optimal Element I.

Assurance to constituents that services necessary to achieve agreed-on goals are provided by encouraging actions of others (public or private), requiring action through regulation, or providing services directly. (B-300)

Current Status When asked, the majority of participants (>90%) attending the trauma system consultation (TSC) were unfamiliar with the Model Trauma System Planning and Evaluation (MTSPE) document produced by the federal Health Resources and Services Administration (HRSA) in 2006. They were also unfamiliar with the Benchmarks, Indicators, and Scoring (BIS) tool contained in the MTSPE document, which can be used to perform a trauma system assessment. No formal statewide BIS process using all 113 indicators has taken place. A subgroup of approximately 12 stakeholders did complete a selection of 16 indicators from the BIS tool that was selected by the American College of Surgeons Committee on 16

Trauma (ACS-COT). It was not surprising to find a wide variance in responses to each of those indicators by the 12 stakeholders. This variance reflects different opinions or knowledge about the development status of components of the state’s trauma system assessed by these indicators. However, the mean scores for each of these 16 indicators will serve as a baseline for discussions between the South Carolina Division of EMS and Trauma and the ACS during a future progress review. Recommendations 

Conduct a facilitated Benchmarks, Indicators and Scoring (BIS) assessment including most, if not all, of the 113 indicators included in the Health Resources and Services Administration Model Trauma System Planning and Evaluation document. o Convene and empower a broad group of stakeholders that represent all aspects of the South Carolina trauma system. o Ensure that a qualified facilitator can help the group achieve consensus and identify priorities for future trauma system development. o Use the findings to identify gaps and misinformation about the current status of trauma system development in South Carolina. o Use information about service gaps and trauma system development priorities to refine the trauma system plan.

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Trauma System Policy Development Statutory Authority and Administrative Rules Purpose and Rationale Reducing morbidity and mortality due to injury is the measure of success of a trauma system. A key element to this success is having the legal authority necessary to improve and enhance care of injured people through comprehensive legislation and through implementing regulations and administrative code, including the ability to regularly update laws, policies, procedures, and protocols. In the context of the trauma system, comprehensive legislation means the statutes, regulations, or administrative codes necessary to meet or exceed a predescribed set of standards of care. It also refers to the operating procedures necessary to continually improve the care of injured patients from injury prevention and control programs through postinjury rehabilitation. The ability to enforce laws and rules guides the care and treatment of injured patients throughout the continuum of care. There must be sufficient legal authority to establish a lead trauma agency and to plan, develop, maintain, and evaluate the trauma system during all phases of care. In addition, it is essential that as the development of the trauma system progresses, included in the legislative mandate are provisions for collaboration, coordination, and integration with other entities also engaged in providing care, treatment, or surveillance activities related to injured people. A broad approach to policy development should include the building of system infrastructure that can ensure system oversight and future development, enforcement, and routine monitoring of system performance; the updating of laws, regulations or rules, and policies and procedures; and the establishment of best practices across all phases of intervention. The success of the system in reducing morbidity and mortality due to traumatic injury improves when all service providers and system participants consistently comply with the rules, have the ability to evaluate performance in a confidential manner, and work together to improve and enhance the trauma system through defined policies. Optimal Elements I. Comprehensive state statutory authority and administrative rules support trauma system leaders and maintain trauma system infrastructure, planning, oversight, and future development. (B-201) a. The legislative authority states that all the trauma system components, emergency medical services (EMS), injury control, incident management, and planning documents work together for the effective implementation of the trauma system (infrastructure is in place). (I-201.2)

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b. Administrative rules and regulations direct the development of operational policies and procedures at the state, regional, and local levels. (I-201.3) II. The lead agency acts to protect the public welfare by enforcing various laws, rules, and regulations as they pertain to the trauma system. (B-311) a. Laws, rules, and regulations are routinely reviewed and revised to continually strengthen and improve the trauma system. (I-311.4) Current Status The Emergency Medical Services (EMS) statute of South Carolina (Title 44, Chapter 61) has a provenance dating back to the 1960’s. The most recent revision went into effect in 2011 with the addition of the Stroke System (Article 6). As it pertains to trauma, 44-61-510-550 of the EMS statute gives the DHEC the authority to: establish a statewide trauma system, create trauma care standards and regulations, designate and de-designate trauma centers, and establish a trauma registry. The DHEC is advised by a Trauma Advisory Council (TAC) with membership specified within the EMS statute. TAC members include representatives from stakeholder agencies and organizations 44-61-540 also establishes the State Trauma Care Fund, which authorizes the DHEC to develop a distribution formula and places responsibility on the DHEC to prioritize disbursements from the State Trauma Care Fund. Unused funds may be carried over to the next fiscal year. The DHEC is not mandated to perform the duties outlined in the EMS statute if there are insufficient monies in the Trauma Care Fund to continue activities. The EMS statute contains a subsection that pertains to confidentiality of the trauma registry data. 44-61-520 is operationalized in regulations contained in R. 61-116 which outlines, in detail, the processes and procedures used to fulfill the DHEC responsibilities under the statute. The stakeholders raised few concerns about 44-61-Article 5 or in the supporting regulations. Three primary themes emerged from participant discussions:   

The need to collect injury data from all acute care facilities (irrespective of designation level or status), The importance of stronger integration of rehabilitation resources, and A concern that the confidentiality subsection of the statute is not sufficient to protect data and the performance improvement processes.

Regulations, by historical reports, should undergo review and potential revision every 35 years. Such has not routinely been the case with R. 61-116.

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Recommendations 

Seek a legal review of the confidentiality section of the EMS statute (Section 44-61-550) and associated regulation (R 61-116, 1004), along with other sections/regulations as needed, to confirm the confidentiality and discoverability protection for peer review to conduct EMS and Trauma Program systemwide performance improvement. o If confidentiality protection is not confirmed, request language to revise and strengthen the EMS statute and the associated regulations so that meaningful systemwide performance improvement can be performed.



Create a broadly representative subcommittee under the authority of the Trauma Advisory Council to review all statutes and regulations pertaining to trauma with a focus on updating and/or revising sections needing attention.

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System Leadership Purpose and Rationale In addition to lead agency staff and consultants (for example, trauma system medical director), there are other significant leadership roles essential to developing mature trauma systems. A broad constituency of trauma leaders includes trauma center medical directors and nurse coordinators, prehospital personnel, injury prevention advocates, and others. This broad group of trauma leaders works with the lead agency to inform and educate others about the trauma system, implements trauma prevention programs, and assists in trauma system evaluation and research to ensure that the right patient, right hospital, and right time goals are met. There is a strong role for the trauma system leadership in conveying trauma system messages, building communication pathways, building coalitions, and collaborating with relevant individuals and groups. The marketing communication component of trauma system development and maintenance begins with a consensus-built public information and education plan. The plan should emphasize the need for close collaboration between coalitions and constituency groups and increased public awareness of trauma as a disease. The plan should be part of the ongoing and regular assessment of the trauma system and be updated as frequently as necessary to meet the changing environment of the trauma system. When there are challenges to providing the optimal care to trauma patients within the system, the leadership needs to effect change to produce the desired results. Broad system improvements require the ability to identify challenges and the resources and authority to make changes to improve system performance. However, system evaluation is a shared responsibility. Although the leadership will have a key role in the acquisition and analysis of system performance data, the multidisciplinary trauma oversight committee will share the responsibility of interpreting those data from a broad systems perspective to help determine the efficiency and effectiveness of the system in meeting its stated performance goals and benchmarks. All stakeholders have the responsibility of identifying opportunities for system improvement and bringing them to the attention of the multidisciplinary committee or the lead agency. Often, subtle changes in system performance are noticed by clinical care providers long before they become apparent through more formal evaluation processes. Perhaps the biggest challenge facing the lead agency is to synergize the diversity, complexity, and uniqueness of individuals and organizations into a finely tuned system for prevention of injury and for the provision of quality care for injured patients. To meet this challenge, leaders in all phases of trauma care must demonstrate a strong desire to work together to improve care provided to injured victims.

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Optimal Elements I.

Trauma system leaders (lead agency, trauma center personnel, and other stakeholders) use a process to establish, maintain, and constantly evaluate and improve a comprehensive trauma system in cooperation with medical, professional, governmental, and other citizen organizations. (B-202)

II.

Collected data are used to evaluate system performance and to develop public policy. (B-205)

III.

Trauma system leaders, including a trauma-specific statewide multidisciplinary, multiagency advisory committee, regularly review system performance reports. (B-206)

IV.

The lead agency informs and educates state, regional, and local, constituencies and policy makers to foster collaboration and cooperation for system enhancement and injury control. (B-207)

Current Status The state of South Carolina has been involved in trauma system development for more than thirty years. Unfortunately, many significant challenges in trauma system leadership have resulted in stagnation and erosion of the trauma system’s structure and function. The current trauma system is based upon a plan and vision that dates back to the mid 1990’s. The trauma system plan has never been updated, and in recent years it has been both literally and functionally lost. Most in the current leadership, including the lead agency, have never seen the document. A copy was found by a stakeholder just prior to the site visit and made available to the TSC team at the time of the consultation. As a result, its elements are only loosely applied in current day-to-day operations. While South Carolina has many energetic stakeholders with strong commitment, the trauma system leadership as a body has neither a unified vision for future development nor a strong set of operational procedures to guide current system function. The multidisciplinary TAC is established in statute and has broad representation. However, the entire membership was replaced recently and is now assuming an active role following a prolonged period of inactivity. The TAC is a large council with a policy development and operational charge. It lacks a clear reporting structure and channel of communication with the DHEC leadership. The recent replacement of all TAC members offers the advantage of including new stakeholders and renewing the council energy, but it lost valuable experience and institutional memory. It was reported that some members of TAC are not fully engaged, and that attendance at quarterly meetings has been sporadic, even when participation by teleconference is possible. This failure to engage was also evident as only 13 TAC members were present during the TSC visit. The TAC does not have well-established rules and procedures for the execution of its duties. If such guidelines existed, they were lost during agency relocations or when a trauma program manager exited and computer files were erased. Decisions regarding 22

trauma center designation are made by a simple majority vote of TAC members present at the time. No established criteria for designation decisions and no formal appeals process were reported to exist. The lack of a structured process for such vital trauma system functions creates an inherent instability and undermines the authority of the TAC, and, by extension, of system leadership as a whole. Neither the TAC nor the lead agency routinely reviews data on system performance, and no plan for ongoing trauma system development was described to the TSC team. As a result, the TAC operates in a reactionary mode, dealing with issues as they arise. Little or no effort has been directed toward maintaining public or legislative awareness of trauma as a public health issue. Similarly, little or no visible effort has been directed toward establishment and maintenance of a coherent public policy addressing trauma as a public health issue. Trauma system leadership is deep within the bureaucratic structure of the DHEC, and trauma system issues do not appear to be a high priority within the DHEC as a whole. The Trauma Association of South Carolina (TASC), an independent non-profit organization made up primarily of trauma program managers and registrars from trauma centers within South Carolina, has played a very active role in system development. Its primary mission was built around education and outreach, as well as mutual assistance among trauma centers. During the recent period of TAC dormancy, much of the TAC’s primary role was assumed by the TASC through default. In the current re-vitalization period, the TASC continues to be utilized to perform much of the hands-on work of the TAC. Even though the TASC has not historically been involved with public awareness and advocacy, this could become a potentially important future role to enhance and support the work of the TAC. The trauma statute does not establish a regional governance structure for the trauma system, but stakeholders report that such a regional infrastructure has been a part of the intended plan and is under development. South Carolina has four EMS regions, and each has at least one Level I or Level II trauma center (two regions have a single Level I center, one region has two Level I centers, and one region has two Level II centers). The current working plan is to adopt the EMS regions as trauma regions, and to use the high-level trauma centers within the region to form the regional organization. Beyond this general concept, no formal structure for regional governance or regional roles and responsibilities was described to the TSC team. It was not apparent that the trauma centers within the regions had been constituted in a functional way about this process. Recommendations 

Formalize the structure and operational activities of the Trauma Advisory Council (TAC), including the identification and establishment of a functional executive committee.



Formalize the rules and procedures for TAC decision making, especially with regard to policy implementation and trauma center designation. 23



Formalize reporting relationships and the communication channel between the TAC and the lead agency.



Establish a unified vision for system development and operation, embodied in the trauma system plan, as a basis for decision making.



Establish a system for succession of TAC members and recruitment of new members to ensure gradual turnover of membership so historical perspectives, vision, and leadership are retained.



Formalize the role of the Trauma Association of South Carolina (TASC) with respect to TAC.



Consider having the TASC assume a role in public awareness and advocacy.



Establish four trauma regions coinciding with the current emergency medical services regions. o Formalize the governance structure and roles and responsibilities for the regions using resources within the high-level trauma centers as a nucleus.

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Coalition Building and Community Support Purpose and Rationale Coalition building is a continuous process of cultivating and maintaining relationships with constituents (interested citizens) in a state or region who agree to collaborate on injury control and trauma system development. Key constituents include health professionals, trauma center administrators, prehospital care providers, health insurers and payers, data experts, consumers and advocates, policy makers, and media representatives. The coalition of key constituents comprises the trauma system’s stakeholders. The involvement of these key constituents is important for the following:      

Trauma system plan development Regionalization: promoting collaboration rather than competition between trauma centers System integration State policy development: authorizing legislation and regulations Financing initiatives Disaster preparedness

The coalition should be effectively organized through the formation of multidisciplinary state and regional advisory groups to coordinate trauma system planning and implementation efforts. Constituents also communicate with elected officials and policy leaders regarding the development and sustainability of the trauma system. Information and education are needed by constituents to be effective partners in policy development for trauma system planning. Regular communication about the status of the trauma system helps these key partners to recognize needs and progress made with trauma system implementation. One of the most effective ways to educate elected officials and the public is through an organized public information and education effort that may involve a media campaign about the burden of injury in the state and the need for trauma system development. Information and education are important to reduce the incidence of injury in all age groups and to demonstrate the value of an effective trauma system when a serious injury occurs. Optimal Element I.

The lead agency informs and educates state, regional, and local constituencies and policy makers to foster collaboration and cooperation for system enhancement and injury control. (B-207)

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Current Status The South Carolina trauma system has a history of engaging many stakeholders in establishing the trauma system and in obtaining legislation and funding. The legislation specifies a TAC with representation from numerous stakeholder organizations that have important roles with regard to the trauma system. A voluntary organization, the TASC, is the most active stakeholder group. The TASC is comprised of key individuals from the designated trauma centers, including the trauma program managers, trauma registrars, injury prevention coordinators, and outreach coordinators. However, as a stakeholder group, it represents only the trauma centers. The South Carolina Hospital Association has provided prior support and advocacy for the trauma system, and continues to be an active stakeholder. A state legislator demonstrated interest in the trauma system by attending a portion of the ACS-COT TSC site visit. The stakeholder group could be substantially strengthened as demonstrated by the limited participation of TAC membership at the TSC public sessions. The active engagement and support by additional individuals and organizations to support an inclusive trauma system is essential, such as non-designated facilities, emergency physicians, EMS and air medical providers, law enforcement, and injury prevention organizations. The entire TAC was recently appointed with all new membership, and face-to-face meetings are held quarterly. Attendance by some official members is reported to be low, and it is not clear that a majority is regularly in attendance, even though teleconference participation is possible. No explanation was provided for the low participation level, and it is unknown if members have been approached to determine reasons for low attendance. The low attendance rate raised concerns among the TSC team about the investment of TAC members in the trauma system. With the complete turnover of TAC membership, a clear vision and focus for the TAC business and the associated roles and responsibilities of TAC members may have been lost. Because the TAC members were appointed so recently, issues such succession planning for trauma system leadership, staggered terms, and reappointment guidelines have not been addressed. No guidelines for conducting TAC business are known to exist. A meeting facilitator would be beneficial to help the TAC membership develop a clear vision for the trauma system, the roles and responsibilities for members, and guidelines for conducting business and decision making. Such a facilitator could be potentially identified in the state’s planning office or the university school of public health. TAC meetings are open to the public and individuals from the designated trauma centers reported that they regularly attend. TAC business is now conducted with a subcommittee structure that sends recommendations to the TAC, and subcommittee membership is inclusive of interested stakeholders. South Carolina had a successful public awareness campaign (in 2003 or 2004) for the trauma system that helped gain support for passage of the State Trauma Care Fund 26

legislation. No recent public awareness effort was reported. The DHEC reported a past experience of using graduate student interns to conduct focus groups for a public health marketing effort which could be a good resource for the trauma system. A TASC member has experience in building an injury prevention coalition that was successful in achieving injury prevention legislation. This TASC member may be a valuable asset to the trauma system. Public access to information about the trauma system is limited. No reports about the value of the trauma system, including its accomplishments, the nature of care provided by trauma centers, and the number of patients treated are prepared and provided to either the public or to elected officials. Information about injuries is difficult to locate on the state website. Communication with known stakeholders was reported to be accomplished primarily by listservs; however, plans to use social media for dissemination of information were described. While these communication methods are valuable, they are targeted to subscribers and less available to individuals searching for information on a state website. Efforts are needed to improve the visibility of information regarding injury and trauma system information through every potential mechanism. Recommendations 

Develop a vision for the South Carolina trauma system to include the roles and responsibilities of the Trauma Advisory Council in implementing this vision. o Use an expert facilitator external to the Division of Emergency Medical Services and Trauma to support this process.



Build a broader coalition (engage state chapters of the Committee on Trauma, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Technicians, voluntary organizations such as Mothers Against Drunk Driving, Kiwanis, Safe Kids, as well as emergency medical technicians, paramedics, flight nurses and paramedics, injury prevention advocates, elected officials, and media representatives).



Develop a plan for raising public awareness about the trauma system and its importance to the state population. o Develop a report about the trauma system, its contribution to the health of South Carolina residents, the nature of injuries treated, and geographic regions with less rapid access to services. o Identify the message to be communicated to the public about the trauma system. o Review the public awareness campaign previously developed and determine what revision would be needed to re-use it. 27

o Identify potential partners and resources (volunteers, student interns, professionals, and funding), for revising the trauma public awareness campaign. 

Ensure that information about the trauma system and links to related programs (e.g. injury and violence prevention) are readily available on the state website and social media outlets.

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Lead Agency and Human Resources Within the Lead Agency Purpose and Rationale Each trauma system (state, regional, local, as defined in state statute) should have a lead agency with a strong program manager who is responsible for leading the trauma system. The lead agency, usually a government agency, should have the authority, responsibility, and resources to lead the planning, development, operations, and evaluation of the trauma system throughout the continuum of care. The lead agency, empowered through legislation, ensures system integrity and provides for program integration with other health care and community-based entities, namely, public health, EMS, disaster preparedness, emergency management, law enforcement, social services, and other community-based organizations. The lead agency works through a variety of groups to accomplish the goals of trauma system planning, implementation, and evaluation. The ability to bring multidisciplinary, multiagency advisory groups together to accomplish trauma system goals is essential in developing and maintaining the trauma system and is part of providing leadership to evolving and mature systems. The lead agency’s trauma system program manager coordinates trauma system design, the adoption of minimum standards (prehospital and in-hospital), and provides for overall system evaluation through performance indicator assessment and assurance. In addition to a trauma program manager, the lead agency must be sufficiently staffed to actively participate in each phase of development and in maintaining the system through a clearly defined structure for decision making (policies and procedures) and through proactive surveillance and evaluation. Minimum staffing usually consists of a trauma system program manager, data entry and analysis personnel, and monitoring and compliance personnel. Additional staff resources include administrative support and a part-time commitment from the public health epidemiology service to provide system evaluation and research support. Within the leadership and governance structure of the trauma system, there is a role for strong physician leadership. This role is usually fulfilled by a full- or part-time trauma medical director within the lead agency. Optimal Elements I. Comprehensive state statutory authority and administrative rules support trauma system leaders and maintain trauma system infrastructure, planning, oversight, and future development. (B-201) a. The legislative authority (statutes and regulations) plans, develops, implements, manages, and evaluates the trauma system and its component parts, including the identification of the lead agency and the designation of trauma facilities. (I201.1) 29

b. The lead agency has adopted clearly defined trauma system standards (for example, facility standards, triage and transfer guidelines, and data collection standards) and has sufficient legal authority to ensure and enforce compliance. (I-201.4). II. Sufficient resources, including financial and infrastructure-related, support system planning, implementation, and maintenance. (B-204) Current Status The DHEC is identified in Title 44, Section 61, Article 5 as the lead agency for trauma system development and implementation for South Carolina. The responsibility of carrying out the provisions set forward has been delegated to the Division of EMS and Trauma within the DHEC. One full-time equivalent (FTE) state trauma program manager (TPM) is the single staff resource committed to trauma system activities. In addition to the trauma program manager, the Division of EMS and Trauma commits relatively small and fragmented portions of time from other division employees to support the state TPM with specific technical assistance with targeted activities and statewide trauma registry trouble-shooting needs. The Division of EMS and Trauma has extended its limited internal staffing to support the trauma system. The trauma system program receives support from the EMS for Children (EMSC) Coordinator who reports to the state TPM. The EMSC Coordinator reportedly contributes approximately 30% of her time towards working with the four EMS regions to implement pediatric specific programs. Additionally, the trauma program has shared access to a data manager located within the Division of EMS and Trauma. The State EMS Medical Director is a contracted position, and this physician serves as the de facto medical director for the trauma program; however, most of the work for this position relates to EMS rather than trauma. The trauma system has a history of receiving limited secured funding to support activities that promote development of a functional integrated trauma system. This program has experienced repeated loss of key staff members that were instrumental in moving trauma system development forward. Trauma center TPMs reported that this repeated change of program leadership has perpetuated a lack of progressive trauma system development. The current state TPM was hired within the last year. In a very short time, the new TPM reached out to trauma stakeholders to revitalize the struggling state trauma system. Even with no direct authority over the trauma system funding and with minimal staffing, the state TPM is to be commended for his accomplishments and the progress made in renewing interest in developing a sustainable statewide trauma program. While some progress has been made, the TSC team perceived that some program activities have been addressed in a reactive rather than a proactive manner. It is 30

common for public health programs that have experienced loss of leadership to reframe and redefine their vision. This is commonly accomplished by developing a tactical plan with established benchmarks for measuring progress. Individual trauma stakeholders and trauma system leadership expressed the need and strong desire to implement a statewide evaluation and performance improvement process. However, the lack of qualified staff such as a performance improvement coordinator and dedicated trauma registrar will continue to hamper these efforts. Recommendations 

Hire additional full time staff to support the state trauma program manager to include a state performance improvement coordinator and a state trauma registrar.



Develop a tactical plan to enable the Division of EMS and Trauma to support development of and to operationalize the comprehensive trauma system plan.



Explore the use of academic interns to support special projects and initiatives for trauma system development.

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Trauma System Plan Purpose and Rationale Each trauma system, as defined in statute, should have a clearly articulated trauma system planning process resulting in a written trauma system plan. The plan should be built on a completed inventory of trauma system resources identifying gaps in services or resources and the location of assets. It should also include an assessment of population demographics, topography, or other access enhancements (location of hospital and prehospital resources) or barriers to access. It is important that the plan identify special populations (for example, pediatric, elderly, in need of burn care, ethnic groups, rural) within the geographic area served and address the needs of those populations within the planning process. A needs assessment (or other method of identifying injury patterns, patient care review/preventable death study) should also be completed for initial trauma system planning and updated periodically as needed to assess system changes over time. The trauma system plan is developed by the lead trauma agency based on the results of a needs assessment and other data resources available for review. It describes the system design, integrated and inclusive, with adopted standards of care for prehospital and hospital personnel and a process to regularly review the plan over time. The plan is built on input from trauma advisory committees (or stakeholder groups) that assist in analyzing data, identifying resources, and developing system standards of care, including system policies and procedures and overall system design. Ideally, although every stakeholder group may not be satisfied with the plan or system design, the plan, to the extent possible, should be based on consensus of the advisory committees and stakeholder groups. These advisory groups should be able to review the plan before final adoption and approve the plan before it is submitted to the lead agency with authority for plan approval. The trauma system plan is used to guide system development, implementation, and management. Each component of the trauma system (for example, prehospital, hospital, communications, and transportation) is clearly defined and an established service level identified (baseline) with goals for enhancement (benchmark). Within the plan are incorporated other planning documents used to ensure integration of similar services and build collaboration and cooperation with those services. Service plans for emergency preparedness, EMS, injury prevention and control, public health, social services, and mental health are examples of services for which the trauma system plan should include an interface between agencies and services. Optimal Element I. The state lead agency has a comprehensive written trauma system plan based on national guidelines. The plan integrates the trauma system with EMS, public health, 32

emergency preparedness, and incident management. The written trauma system plan is developed in collaboration with community partners and stakeholders. (B-203) a. The trauma system plan clearly describes the system design (including the components necessary to have an integrated and inclusive trauma system) and is used to guide system implementation and management. For example, the plan includes references to regulatory standards and documents and includes methods of data collection and analysis. (I-203.4) Current Status A major strength of South Carolina’s current trauma system environment is the commitment of the medical community and the facilities at the grassroots level statewide. While efforts to develop a trauma system plan were productive in the past, the resulting 1995 plan was not comprehensive and did not use an inclusive trauma system model (e.g., all hospitals with an emergency department have a role in the trauma system). With no revision of the 1995 plan, the current state of the trauma system is undefined, and trauma system development and improvement has stalled. The Division of EMS and Trauma acknowledges this shortfall which led to the request for an ACS-COT trauma system consultation. The 1995 trauma system plan could serve as a good foundation for the development of a modern trauma system plan. Important steps for trauma system planning include a comprehensive resource listing and a formal needs assessment to help identify gaps. These identified gaps can then be prioritized leading to development of a specific strategy for improvement. Essential partners include the EMS agencies, designated trauma centers, non-designated hospitals, emergency managers, physicians, emergency nurses, along with other core members of the health care team. Various specialty and academic societies should be represented as well. The 2006 HRSA Model Trauma System Planning and Evaluation (MTSPE) document should be consulted during development of the trauma system plan to help align it within a public health framework and to also enhance discussion related to the interface between the trauma system and disaster preparedness. See Table 3 on page 16 of the MTSPE document for a listing of the essential services and trauma system components. Trauma system planning for South Carolina may benefit from review of plans developed by other states that are integrative, inclusive, and emphasize the public health framework. Examples may include Colorado, Minnesota, and North Dakota. Recommendations 

Develop a comprehensive trauma system plan using the authority of the existing enabling legislation. o Review and revise the plan on a scheduled basis, e.g. every 3-5 years.

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

Ensure that the trauma system plan is developed with key elements. o Integrate public health principles contained in the 2006 Model Trauma System Planning and Evaluation document published by the federal Health Resources and Services Administration. o Review trauma system plans from other states that are based on integrated and inclusive trauma system model principles. o Align existing resources (fiscal and human) with the priority tasks. o Develop all objectives, strategies, and tasks in a measurable and time referenced framework with specific agencies, entities, or individuals assigned to each process. o Assign accountability for the monitoring and completion of the plan to a single agency or entity. o Complete the first draft within 6 months upon receipt of this report.



Perform a needs assessment that includes a comprehensive accounting of all the trauma system resources (statewide and bordering states) and conduct a gap analysis. o Include the following resources: public safety answering points, 911 agencies, acute care hospitals, trauma centers, subspecialty care hospitals, rehabilitation facilities, long term care facilities, emergency management agencies, and disaster response agencies. o Ensure a comprehensive assessment of capability and capacity.

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System Integration Purpose and Rationale Trauma system integration is essential for the daily care of injured people and includes such services as mental health, social services, child protective services, and public safety. The trauma system should use the public health approach to injury prevention to contribute to reducing the entire burden of injury in a state or region. This approach enables the trauma system to address primary, secondary, and tertiary injury prevention through closer integration with community health programs and mobilizing community partnerships. The partnerships also include mental health, social services, child protection, and public safety services. Collaboration with the public health community also provides access to health data that can be used for system assessment, development of public policy, and informing and educating the community. Integration with EMS is essential because this system is linked with the emergency response and communication infrastructure and transports severely injured patients to trauma centers. Triage protocols should exist for treatment and patient delivery decisions. Regulations and procedures should exist for online and off -line medical direction. In the event of a disaster affecting local trauma centers, EMS would have a major role in evacuating patients from trauma centers to safety or to other facilities or to make beds available for patients in greater need. The trauma system is a significant state and regional resource for the response to mass casualty incidents (MCIs). The trauma system and its trauma centers are essential for the rapid mobilization of resources during MCIs. Preplanning and integration of the trauma system with related systems (public health, EMS, and emergency preparedness) are critical for rapid mobilization when a disaster or MCI occurs. The extensive impact of disasters and MCIs on the functioning of trauma centers and the EMS and public health systems within the affected region or state must be considered, and joint planning for optimal use of all resources must occur to enable a coordinated response to an MCI. Trauma system leaders need to be actively involved in emergency management planning to ensure that trauma centers are integrated into the local, regional, and state disaster response plans. Optimal Elements I. The state lead agency has a comprehensive written trauma system plan based on national guidelines. The plan integrates the trauma system with EMS, public health, emergency preparedness, and incident management. The written trauma system plan is developed in collaboration with community partners and stakeholders. (B-203) a. The trauma system plan has established clearly defined methods of integrating the trauma system plan with the EMS, emergency, and public health preparedness plans. (I-203.7) 35

II. The trauma, public health, and emergency preparedness systems are closely linked. (B-208) Current Status Organizationally, the trauma system program is an office within the Division of Emergency Medical Services and Trauma, under the Bureau of Health Facilities and Services Development within the Health Regulation section, and under the Director of Public Health within the Department of Health and Environmental Control (DHEC). The number of administrative levels between the trauma system program and key higher level leadership in the lead agency will make it more challenging to gain support for the integration of the trauma system and emergency medical services with other important public health programs. The current organizational architecture does present a potential framework for integration of the trauma system because of the administrative proximity of the trauma system, EMS, and Emergency Medical Services for Children (EMSC) programs. Legislation was passed recently to establish a stroke program; however, it was unclear to the TSC team where the administration for this program resides. An opportunity exists for enhanced interaction between these four key programs that are focused on time-critical diseases. ST elevation myocardial infarction (STEMI) is a third time-critical disease that does not yet have a legislatively established program in South Carolina. The emerging recognition of the public health importance of time-critical diseases (trauma, STEMI, and stroke) could offer a potential opportunity to create a common infrastructure for management (e.g., information technology and registry requirements, leadership, facility designation, public relations, and education). An opportunity for organizational restructuring exists for placing these programs into one bureau to improve resource utilization and to potentially raise the visibility of these programs among the DHEC leadership. A re-invigorated TAC demonstrates the potential for improved trauma system integration. The trauma system legislation establishes a broad, multidisciplinary crosssection of specialties and agencies participating in trauma care for TAC membership. If the TAC meetings are well attended and members are guided by a well-structured trauma system plan, the TAC will be well positioned to set the tone for integration of the trauma system within the overall South Carolina health system. The 1995 trauma system plan has limited vision and integration with the various programs and disciplines involved in a statewide trauma system. The plan is dated in its content and construction, and as such, it does not serve as a framework for continual trauma system improvement. In the absence of a well-defined trauma system plan, multiple information and functional silos have developed regarding management of the injured patient. As a result, the current state trauma system is not integrated with important functions and programs addressing injury prevention, emergency preparedness, hospital preparedness, traumatic brain injury and spinal cord injury, mental health, law enforcement, public safety answering points (PSAPs) and EMS dispatch, and rehabilitation. 36

Recommendations 

Ensure that the state trauma system plan creates the overarching climate supporting integration across the continuum of services.



Align the trauma system program with other time-critical disease programs (stroke and STEMI) and elevate the level of its reporting relationship within the DHEC.



Develop regional advisory committees to facilitate integration efforts and enhance stakeholder participation.

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Financing Purpose and Rationale Trauma systems need sufficient funding to plan, implement, and evaluate a statewide or regional system of care. All components of the trauma system need funding, including prehospital, acute care facilities, rehabilitation, and prevention programs. Lead agency trauma system management requires adequate funding for daily operations and other important activities such as advisory committee meetings, development of regulations, data collection, performance improvement, and public awareness and education. Adequate funding to support the operation of trauma centers and their state of readiness to care for seriously injured patients within the state or region is essential. The financial health of the trauma system is essential for ensuring its integrity and its improvement over time. The trauma system lead agency needs a process for assessing its own financial health, as well as that of the trauma system. A trauma system budget should be prepared, and costs should be reported by each component, if possible. Routine collection of financial data from all participating health care facilities is encouraged to fully identify the costs and revenues of the trauma system, including costs and revenues pertaining to patient care, administrative, and trauma center operations. When possible, the lead agency financial planning should integrate with the budgets and costs of the EMS system and disaster, rehabilitation, and prevention programs to enable development of a comprehensive financial health report. Trauma system financial planning should be related to the trauma plan outcome measures (for example, patient outcome measures such as mortality rates, length of stay, and quality-of-life indicators). Such information may demonstrate the value added by having a trauma system in place. Optimal Elements I. Sufficient resources, including financial and infrastructure-related, support system planning, implementation, and maintenance. (B-204) a. Financial resources exist that support the planning, implementation, and ongoing management of the administrative and clinical care components of the trauma system. (I 204.2) b. Designated funding for trauma system infrastructure support (lead agency) is legislatively appropriated. (I-204.3) c. Operational budgets (system administration and operations, facilities administration and operations, and EMS administration and operations) are aligned with the trauma system plan and priorities. (I-204.4)

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II. The financial aspects of the trauma systems are integrated into the overall performance improvement system to ensure ongoing fine tuning and cost-effectiveness. (B-309) a. Collection and reimbursement data are submitted by each agency or institution on at least an annual basis. Common definitions exist for collection and reimbursement data and are submitted by each agency. (I-309.2) Current Status South Carolina is very fortunate to have the State Trauma Care Fund established by the legislature (Section 44-61-540), and an annual appropriation has been made since its establishment. Rules have been written that define the formula for disbursement of these funds. The largest portion is disbursed to designated trauma centers and physicians, and some funding is provided to the EMS Regional Training Centers as well as to EMS agencies in counties with the highest accident fatality rates per capita. The funding is an annual appropriation by the state legislature, but it is not based on a more permanent revenue mechanism, such as a fine or fee. The initial appropriation to the State Trauma Care Fund was $6 million, and the appropriation has decreased over time. For Fiscal Year (FY) 2014, $2.268 million was appropriated. The current formula for disbursement provides only 2.5% of the appropriated funds to the DHEC for administration of the trauma program, which was approximately $57,000 for FY 2014. Funding is currently inadequate to support operational functions for an inclusive state trauma system program, such as essential personnel (trauma program manager, trauma registrar, performance improvement coordinator), strategic planning, a statewide trauma registry, and travel expenses for members of the advisory committee. Each year, the DHEC submits a proposed agency budget that includes a line item for the State Trauma Care Fund. The legislature can accept or modify the requested funding request. The DHEC budget proposal process occurs at an administrative level above the Division of EMS and Trauma. The degree to which the Director of the Division of EMS and Trauma has a proactive role in budget planning for program management was unclear to the TSC team. The statute language for the State Trauma Care Fund specifically outlines the importance of operational functions of the trauma system. Section 44-61-540(B) states: “The fund must be a separate and distinct fund for the payment of the Department of Health and Environmental Control’s expenses in establishing, administering, and overseeing the Trauma Care System. After payment of the department’s operating expenses from the fund, the department may authorize and allocate the distribution of any remaining funds for any and all of the following purposes: …”

39

A mechanism thus exists for assuring that financial resources are adequate to support the essential administration and operation of the trauma system program, however, the funding formula regulation will need to be revised. The current rules for disbursement of the State Trauma Care Fund are very focused on individual trauma centers rather than on an inclusive trauma system. Funds are provided to help cover uncompensated care in trauma centers and for physicians. While the funds provided to the designated trauma centers may help gain the support of hospital administrators for trauma center activities, it is unclear if the individual trauma center programs directly benefit. The original intent of funds to the EMS Regional Training Centers was to ensure provision of trauma education to EMS providers. It was reported that the function of Regional Training Centers has changed from coordination of all EMS education, including continuing education, to become sites for initial EMS training and National Registry testing sites. Trauma education for EMS providers is now integrated into training programs at other locations. The funds from the State Trauma Care Fund are provided as a “pass through” to the hospitals and other designated recipients. Recipients are asked to acknowledge that funds will be used for the stated purpose in the budget appropriations proviso. No specific expectations are associated with accepting the funding, such as an annual report of the program accomplishments, timely submission of trauma registry data, education outreach, participation in regional and state committees, or an audit of how funds are used. Because of staff turnover, the state trauma system program has not sought opportunities for grant funding that could support program efforts, such as the Office of Rural Health Rural Hospital Flexibility grant, emergency preparedness funds, or Department of Transportation 402 and 408 funding. Some grant funding has been provided to support trauma training, such as the Rural Trauma Team Development Course (RTTDC), but this was an initiative of one trauma center. Some support for RTTDC was noted to be included in the FY 16 budget for the South Carolina Office of Rural Health. A funding subcommittee of the TAC has been created. Options for sources of a permanent revenue source for the State Trauma Care Fund have been investigated in the past, but additional investigation of revenue streams is encouraged, such as gaming revenue, cell phone surcharges, and fees associated with tourism. When a question was asked about trauma center collection of trauma activation fees, responses indicated that some trauma centers either did not charge or did not know whether these fees were charged to the Centers for Medicare and Medicaid Services and private insurance payers. This is a potential source of revenue for trauma centers that each could be encouraged to explore.

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Recommendations 

Realign the disbursement of the State Trauma Care Fund to provide a larger portion for state trauma system program operations as outlined in the statute.



Secure a permanent revenue source for the State Trauma Care Fund through a fee or fine mechanism. o Consider gaming revenue, cell phone surcharge, NASCAR parking fee, and other potential fees associated with tourism.



Provide funding for the Regional Trauma Councils.



Identify specific expectations for the trauma centers (e.g. participation in regional and state trauma system planning, timely submission of registry data, and outreach activities), and other recipients of the State Trauma Care Fund as a condition of receiving funds, and require a report outlining how expectations are met.

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Trauma System Assurance Prevention and Outreach Purpose and Rationale Trauma systems must develop prevention strategies that help control injury as part of an integrated, coordinated, and inclusive trauma system. The lead agency and providers throughout the system should be working with business organizations, community groups, and the public to enact prevention programs and prevention strategies that are based on epidemiologic data gleaned from the system. Efforts at prevention must be targeted for the intended audience, well defined, and structured, so that the impact of prevention efforts is system-wide. The implementation of injury control and prevention requires the same priority as other aspects of the trauma system, including adequate staffing, partnering with the community, and taking advantage of outreach opportunities. Many systems focus information, education, and prevention efforts directly to the general public (for example, restraint use, driving while intoxicated). However, a portion of these efforts should be directed toward emergency medical services (EMS) and trauma care personnel safety (for example, securing the scene, infection control). Collaboration with public service agencies, such as the department of health is essential to successful prevention program implementation. Such partnerships can serve to synergize and increase the efficiency of individual efforts. Alliances with multiple agencies within the system, hospitals, and professional associations, working toward the formation of an injury control network, are beneficial. Activities that are essential to the development and implementation of injury control and prevention programs include the following: • A needs assessment focusing on the public information needed for media relations, public officials, general public, and third-party payers, thus ensuring a better understanding of injury control and prevention • Needs assessment for the general medical community, including physicians, nurses, prehospital care providers, and others concerning trauma system and injury control information • Preparation of annual reports on the status of injury prevention and trauma care in the system • Trauma system databases that are available and usable for routine public health surveillance Optimal Elements I. The lead agency informs and educates state, regional, and local constituencies and policy makers to foster collaboration and cooperation for system enhancement and injury control. (B-207) 42

a. The trauma system leaders (lead agency, advisory committees, and others) inform and educate constituencies and policy makers through community development activities, targeted media messaging, and active collaborations aimed at injury prevention and trauma system development. (I-207.2) II. The jurisdictional lead agency, in cooperation with other agencies and organizations, uses analytic tools to monitor the performance of population based prevention and trauma care services. (B-304) a. The lead agency, along with partner organizations, prepares annual reports on the status of injury prevention and trauma care in state, regional, or local areas. (I-304.1) III. The lead agency ensures that the trauma system demonstrates prevention and medical outreach activities within its defined service area. (B-306) a. The trauma system is active within its jurisdiction in the evaluation of community based activities and injury prevention and response programs. (I-306.2) b. The effect or impact of outreach programs (medical and community training and support and prevention activities) is evaluated as part of a system performance improvement process. (I-306.3) Current Status Currently, numerous injury prevention and outreach efforts are being conducted in South Carolina. Many of these programs were initiated by the level I and II trauma centers, the TASC, and the DVIP. The DVIP formed the South Carolina Injury Free Alliance. Other injury prevention programs are sponsored by numerous organizations throughout the state. The DVIP and the trauma centers are integrating many of their injury prevention efforts collaboratively with these organizations. In 2010, the DVIP developed an Injury Prevention Plan (2010-2015), which is based on the public health model. This plan was created by a group of stakeholders from numerous DHEC Divisions, representatives from some of the trauma centers, and various injury advocacy groups from across the state. This plan identified intentional and unintentional injury as the leading cause of death in state residents between 1 to 44 years of age. The top 5 leading causes of injury mortality and the associated medical costs were identified. Workgroups of the Injury Free Alliance reviewed data from multiple reliable sources and identified priority areas of injury prevention focus. Each priority area has a vision and mission statement, a list of priority initiatives, objectives, strategies, activities, and references. The priority injury prevention issues addressed include the following:   

Unintentional poisoning, Falls among older adults, Suicide, 43

    

Child maltreatment, Traumatic brain and spinal cord injuries, Child passenger safety, Sexual violence, and Residential fire.

The DVIP Injury Prevention Plan was widely distributed throughout the state including among the trauma program managers from the trauma centers. Implementation of the injury prevention plans has begun, and some accomplishments were reported. The TASC focused on falls in older adults in 2013. Efforts included an educational brochure, a press release, and participation in local and regional events during national falls prevention week. An evaluation of the falls prevention program is planned using the trauma registry for baseline and follow-up data. An identified goal of fall reduction hospitalizations by 2% in five years was established. The DVIP and associates also participate in the American Trauma Society’s National Trauma Awareness month. The Injury Free Alliance activity waned when the CDC funding ended; however, efforts to reinvigorate the Injury Free Alliance are underway. The DVIP worked collaboratively with injury prevention partners on two legislative campaigns:  

A school concussion prevention initiative and A wheel locking, driving under the influence (DUI) initiative.

Both initiatives resulted in successful passage of legislation. These two initiatives should be considered models that illustrate methods to bring the trauma system, trauma centers, and trauma funding initiatives to the forefront, grasping the attention of elected officials. No calendar of events was posted on the DVIP website at the time of the TSC visit. It was reported that the DVIP has the ability to post injury prevention events, and an interest was expressed in pursuing this. The current DVIP website has no section that could serve as a clearinghouse or compilation of injury prevention programs and initiatives offered statewide. The Trauma System Program is initiating collaboration with the trauma centers, TASC, and the leadership from the DVIP. Time, lack of additional personnel resources, and competing priorities limit the ability of the state TPM to become fully integrated into comprehensive statewide injury prevention activities. No specific plan for increasing collaboration between the state TPM and the DVIP leadership was discussed with the TSC team. The DVIP office is relocating and will be within close proximity to the Division of EMS and Trauma, and it was stated that proximity will help to enhance collaborative efforts. The TASC is a non-profit organization whose membership consists of TPM’s, trauma registrars, performance improvement coordinators, and injury prevention coordinators 44

from the designated trauma centers. The TASC members meet monthly. Some activities of the TASC include the following:     

Coordination of an annual trauma symposium, Completing the data dictionary, Injury prevention initiatives, Mentoring, and Continuing education.

TASC recently rolled out the Society of Trauma Nurses’ Electronic Library of Trauma Lectures which allows for a flexible continuing educational delivery system throughout the state. An additional educational endeavor of note was the trauma designation site reviewer educational session offered at the annual symposium. This was aligned strategically with the needs of the state trauma system. TASC is a financially-sound organization. Routine communication between the TASC members occurs through their list serve. This organization is motivated to continue evolving its development, and it plans to develop a mission and vision statement. Consideration should be given to developing a strategic plan which would act as a compass, helping to set priorities and to focus the TASC activities with assigned work groups, leaders, and target deadlines. The TASC meeting agenda routinely provides time for a report from the DVIP Injury Prevention Subcommittee and the state TPM, encouraging close collaboration between these state programs and the TASC members. TASC also donated $5,000 to the State Injury Prevention Subcommittee for outreach endeavors for 2014 and waived the registration fee for officers of this subcommittee. The TASC has no mechanism for tracking, collating, and reporting its activities of the group, other than meeting minutes. The TASC members recently created a website committee to begin identifying additional resources to post. Information about all of the education outreach activities of the trauma centers (courses offered, schedules, numbers of instructors and students, etc.) would be valuable for the trauma system. Numerous trauma outreach efforts occur in South Carolina. Most efforts are coordinated and offered by the level I and II trauma centers for hospitals within their referral area. Examples of some of these outreach efforts are: the Rural Trauma Team Development Course (RTTDC), Advanced Trauma Life Support (ATLS), Advanced Trauma Care for Nurses (ATCN), and the Trauma Nurse Core Course (TNCC). Trauma centers are encouraged to continue to augment their current program with incoming instructors thus allowing for an increase in the number of courses offered without burning out current instructors. Recommendations 

Complete the Division of Violence and Injury Prevention website development and expand content to support statewide activities and outreach. 45

o Ensure that links to injury prevention programs, initiatives, and tools are available for organizations and the public. 

Compile a comprehensive list of evidence-based injury prevention programs offered by various organizations in the state and post on a website. o Determine whether to maintain this information on a state website or the website of an organization with an injury prevention focus. o Update the list annually.



Reinvigorate the South Carolina Injury Free Alliance and include all injury prevention and trauma stakeholders.



Create reports highlighting the numbers of educational programs, outreach programs, and injury prevention programs offered annually, and disseminate them to key stakeholders.



Post a calendar of events for state injury prevention and education outreach activities on a website with wide public access.



Increase the instructor pool for trauma outreach educational programs.

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Emergency Medical Services Purpose and Rationale The trauma system includes, and/or interacts with, many different agencies, institutions, and systems. The EMS system is one of the most important of these relationships. EMS is often the critical link between the injury-producing event and definitive care at a trauma center. Even though at its inception the EMS system was a very broad system concept, over time, EMS has come to be recognized as the prehospital care component of the larger emergency health care system. It is a complex system that not only transports patients, but also includes public access, communications, personnel, triage, data collection, and quality improvement activities. The EMS system medical director must have statutory authority to develop protocols, oversee practice, and establish a means of ongoing quality assessment to ensure the optimal provision of prehospital care. If not the same individual, the EMS system medical director must work closely with the trauma system medical director to ensure that protocols and goals are mutually aligned. The EMS system medical director must also have ongoing interaction with EMS agency medical directors at local levels, as well as the state EMS for Children program, to ensure that there is understanding of and compliance with trauma triage and destination protocols. Ideally, a system should have some means of ensuring whether resources meet the needs of the population. To achieve this end, a resource and needs assessment evaluating the availability and geographic distribution of EMS personnel and physical resources is important to ensure a rapid and appropriate response. This assessment includes a detailed description of the distribution of ground ambulance and aeromedical locations across the region. Resource allocations must be assessed on a periodic basis as needs dictate a redistribution of resources. In communities with full-time paid EMS agencies, ambulances should be positioned according to predictable geographic or temporal demands to optimize response efficiencies. Such positioning schemes require strong prehospital data collection systems that can track the location of occurrences over time. Periodic assessment of dispatch and transport times will also provide insight into whether resources are consistent with needs. Each region should have objective criteria dictating the level of response (advanced life support [ALS], basic life support [BLS]), the mode of transport, and the disposition of the patient based on the location of the incident and the severity of injury. A mechanism for case-based review of trauma patients that involves prehospital and hospital providers allows bidirectional information sharing and continuing education, ensuring that expectations are met at both ends. Ongoing review of triage and treatment decisions allows for continuing quality improvement of the triage and prehospital care protocols. A more detailed discussion of in-field (primary) triage criteria is provided in the section titled: System Coordination and Patient Flow (p 20) (White Book). Human Resources 47

Periodic workforce assessments of EMS should be conducted to ensure adequate numbers and distribution of personnel. EMS, not unlike other health care professions, experiences shortages and maldistribution of personnel. Some means of addressing recruitment, retention, and engagement of qualified personnel should be a priority. 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 core curricula for Emergency Medical Responder, Emergency Medical Technician (EMT), Advanced EMT, Paramedic, and other levels of prehospital personnel have an essential orientation to trauma care for all ages. However, trauma care knowledge and skills need to be continuously updated, refined, and expanded through targeted trauma care training such as Prehospital Trauma Life Support®, Basic Trauma Life Support®, and age-specific courses. Mechanisms for the periodic assessment of competence, educational needs, and education availability within the system should be incorporated into the trauma system plan. Systems of excellence also encourage EMS providers to go beyond meeting state standards for agency licensure and to seek national accreditation. National accreditation standards exist for ground-based and air medical agencies, as well as for EMS educational programs. In some states, agency licensure requirements are waived or substantially simplified if the EMS agency maintains national accreditation. EMS is the only component of the emergency health care and trauma system that depends on a large cadre of volunteers. In some states, substantially more than half of all EMS agencies are staffed by volunteers. These agencies typically serve rural areas and are essential to the provision of immediate care to trauma patients, in addition to provision of efficient transportation to the appropriate facility. In some smaller facilities, EMS personnel also become part of the emergency resuscitation team, augmenting hospital personnel. The trauma care system program should reach out to these volunteer agencies to help them achieve their vital role in the outcome of care of trauma patients. However, it must be noted that there is a delicate balance between expecting quality performance in these agencies and placing unrealistic demands on their response capacity. In many cases, it is better to ensure that there is an optimal BLS response available at all times rather than a sporadic or less timely response involving ALS personnel. Support to volunteer EMS systems may be in the form of quality improvement activities, training, clinical opportunities, and support to the system medical director. Owing to the multidisciplinary nature of trauma system response to injury, conferences that include all levels of providers (for example, prehospital personnel, nurses, and physicians) need to occur regularly with each level of personnel respected for its role in the care and outcome of trauma patients. Communication with and respect for prehospital providers is particularly important, especially in rural areas where exposure to major trauma patients might be relatively rare. Integration of EMS Within the Trauma System 48

In addition to its critical role in the prehospital treatment and transportation of injured patients, EMS must also be engaged in assessment and integration functions that include the trauma system and also public health and other public safety agencies. EMS agencies should have a critical role in ensuring that communication systems are available and have sufficient redundancy so that trauma system stakeholders will be able to assess and act to limit death and disability at the single patient level and at the population level in the case of mass casualty incidents (MCIs). Enhanced 911 services and a central communication system for the EMS/trauma system to ensure field-tofacility bidirectional communications, interfacility dialogue, and all-hazards response communications among all system participants are important for integrating a system’s response. Wireless communications capabilities, including automatic crash notification, hold great promise for quickly identifying trauma-producing events, thereby reducing delays in discovery and decreasing prehospital response intervals. Further integration might be accomplished through the use of EMS data to help define high-risk geographic and demographic characteristics of injuries within a response area. EMS should assist with the identification of injury prevention program needs and in the delivery of prevention messages. EMS also serves a critical role in the development of all-hazards response plans and in the implementation of those plans during a crisis. This integration should be provided by the state and regional trauma plan and overseen by the lead agency. EMS should participate through its leadership in all aspects of trauma system design, evaluation, and operation, including policy development, public education, and strategic planning. Optimal Elements I. The trauma system is supported by an EMS system that includes communications, medical oversight, prehospital triage, and transportation; the trauma system, EMS system, and public health agency are well integrated. (B-302) a. There is well-defined trauma system medical oversight integrating the specialty needs of the trauma system with the medical oversight for the overall EMS system. (I-302.1) b. There is a clearly defined, cooperative, and ongoing relationship between the trauma specialty physician leaders (for example, trauma medical director within each trauma center) and the EMS system medical director. (I-302.2) c. There is clear-cut legal authority and responsibility for the EMS system medical director, including the authority to adopt protocols, to implement a performance improvement system, to restrict the practice of prehospital care providers, and to generally ensure medical appropriateness of the EMS system. (I-302.3) d. The trauma system medical director is actively involved with the development, implementation, and ongoing evaluation of system dispatch protocols to ensure they are congruent with the trauma system design. These protocols include, but are not limited to, which resources to dispatch, for example, ALS versus BLS, airground coordination, early notification of the trauma care facility, prearrival 49

instructions, and other procedures necessary to ensure that resources dispatched are consistent with the needs of injured patients. (I-302.4) e. The retrospective medical oversight of the EMS system for trauma triage, communications, treatment, and transport is closely coordinated with the established performance improvement processes of the trauma system. (I302.5) f. There is a universal access number for citizens to access the EMS/trauma system, with dispatch of appropriate medical resources. There is a central communication system for the EMS/trauma system to ensure field- to- facility bidirectional communications, interfacility dialogue, and all-hazards response communications among all system participants. (I-302.7) g. There are sufficient and well-coordinated transportation resources to ensure that EMS providers arrive at the scene promptly and expeditiously transport the patient to the correct hospital by the correct transportation mode. (I-302.8) II. The lead trauma authority ensures a competent workforce. (B-310) a. In cooperation with the prehospital certification and licensure authority, set guidelines for prehospital personnel for initial and ongoing trauma training, including trauma-specific courses and courses that are readily available throughout the state. (I-310.1) b. In cooperation with the prehospital certification and licensure authority, ensure that prehospital personnel who routinely provide care to trauma patients have a current trauma training certificate, for example, Prehospital Trauma Life Support or Basic Trauma Life Support and others, or that trauma training needs are driven by the performance improvement process. (I-310.2) c. Conduct at least 1 multidisciplinary trauma conference annually that encourages system and team approaches to trauma care. (I-310.9) III. The lead agency acts to protect the public welfare by enforcing various laws, rules, and regulations as they pertain to the trauma system. (B-311) a. Incentives are provided to individual agencies and institutions to seek state or nationally recognized accreditation in areas that will contribute to overall improvement across the trauma system, for example, Commission on Accreditation of Ambulance Services for prehospital agencies, Council on Allied Health Education Accreditation for training programs, and American College of Surgeons (ACS) verification for trauma facilities. (I-311.6) Current Status The Division of EMS and Trauma within the DHEC has the authority to regulate EMS services. Municipalities and counties at the local level have no specific requirement to ensure that community residents have access to EMS, unlike the requirement that 50

ensures community fire and law enforcement services. The EMS system provides patient care primarily by “home rule” which is associated with inconsistency, virtually no incentive for standardization of care, and wide variation in use of introspective performance improvement. This structure limits the ability of the current EMS system to integrate with systems of care for the treatment of patients who have serious injuries or other acute time-critical diseases that require coordinated care, appropriate triage, and transport to receiving facilities with specialized resources. South Carolina has 46 counties, and each designates its own emergency transport service provider. The diversity of emergency transport service providers include firebased, private contract third service models, hospital-based models, volunteer/rescue squads, and public safety. Clear and dramatic progress in the availability of E9-1-1 throughout the state has occurred. At the time of the TSC visit, 41 of the 46 counties had this essential public safety resource. EMS services across the state provide varying levels of care at the advanced life support (ALS) and basic life support (BLS) levels. Various levels of provider training also occur in the regions. Fourteen air ambulances operate in South Carolina, and they are stationed at various locations within the state. Eight agencies that offer specialty care to pediatric patients are permitted to operate in the state. The current version of EMS regulations identifies a credentialing process for emergency medical technician (EMT)-Basic, EMT-Intermediate, and Paramedic. These prehospital identifiers are being changed to correspond with national nomenclature. The state should be commended for adopting the standards of and adhering to the National Registry of EMTs (NREMT) credentialing process for all levels of providers. This relationship with the National Registry will support the transition of South Carolina EMS providers to the current nomenclature and associated EMT, Advanced EMT, and Paramedic recognition levels. The state has four EMS Regions, and each region has a State EMS Training Center under contract with the Division of EMS and Trauma. Each training region is responsible for providing training and serves as an NREMT test site. An EMS Advisory Council has been established to assist with the review and development of standards for the improvement of emergency medical services within the state. The council is advisory to the EMS program and the State EMS Medical Director. Recommended statewide EMS protocols exist, and the most current version was approved in 2010. These protocols serve as a suggested template, but leadership in the Division of EMS and Trauma reported variation in the use of these protocols. Of particular note, the current protocols are often referred to as guidelines. An individual agency medical director may extract from these protocols and write agency-specific protocols. The recommended statewide EMS protocols include a field triage and bypass

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protocol (# 59, dated 2009). The guideline is used to determine trauma injuries; however, it directs the reader to the Trauma Plan to determine a transport destination. The state has implemented and continues to support an electronic patient care reporting program. The ePCR that adheres to a standard data dictionary is useful in establishing a data repository. It was reported that valuable reports can be produced in real time. Recommendations 

Refine prehospital trauma field triage protocol to include prescriptive regional destination criteria as it relates to trauma patients.



Update an agreed upon set of protocols that serve as the statewide standard of care for trauma patients.

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Definitive Care Facilities Purpose and Rationale Inclusive trauma systems are the systems that include all acute health care facilities, to the extent that their resources and capabilities allow and in which the patient’s needs are matched to hospital resources and capabilities. Thus, as the core of a regional trauma system, acute care facilities operating within an inclusive trauma system provide definitive care to the entire spectrum of patients with traumatic injuries. Acute care facilities must be well integrated into the continuum of care, including prevention and rehabilitation, and operate as part of a network of trauma-receiving hospitals within the public health framework. All acute care facilities should participate in the essential activities of a trauma system, including performance improvement, data submission to state or regional registries, representation on regional trauma advisory committees, and mutual operational agreements with other regional hospitals to address interfacility transfer, educational support, and outreach. The roles of all definitive care facilities, including specialty hospitals (for example, pediatric, burn, severe traumatic brain injury [TBI], spinal cord injury [SCI]) within the system should be clearly outlined in the regional trauma plan and monitored by the lead agency. Facilities providing the highest level of trauma care are expected to provide leadership in education, outreach, patient care, and research and to participate in the design, development, evaluation, and operation of the regional trauma system. In an inclusive system, patients should be triaged to the appropriate facility based on their needs and facility resources. Patients with the least severe injuries might be cared for at appropriately designated facilities within their community, whereas the most severe should be triaged to a Level I or II trauma center. In rural and frontier systems, smaller facilities must be ready to resuscitate and initiate treatment of the major injuries and have a system in place that will allow for the fastest, safest transfer to a higher level of care. Trauma receiving facilities providing definitive care to patients with other than minor injuries must be specifically designated by the state or regional lead agency and equipped and qualified to do so at a level commensurate with injury severity. To assess and ensure that injury type and severity are matched to the qualifications of the facilities and personnel providing definitive care, the lead agency should have a process in place that reviews and verifies the qualifications of a particular facility according to a specific set of resource and quality standards. This criteria-based process for review and verification should be consistent with national standards and be conducted on a periodic cycle as determined by the lead agency. When centers do not meet set standards, there should be a process for suspension, probation, revocation, or dedesignation. Designation by the lead agency should be restricted to facilities meeting criteria or statewide resource and quality standards and based on patient care needs of the regional trauma system. There should be a well-defined regulatory relationship between 53

the lead agency and designated trauma facilities in the form of a contract, guidelines, or memorandum of understanding. This legally binding document should define the relationships, roles, and responsibilities between the lead agency and the medical leadership from each designated trauma facility. The number of trauma centers by level of designation and location of acute care facilities must be periodically assessed by the lead agency with respect to patient care needs and timely access to definitive trauma care. There should be a process in place for augmenting and restricting, if necessary, the number and/or level of acute care facilities based on these periodic assessments. The trauma system plan should address means for improving acute care facility participation in the trauma system, particularly in systems in which there has been difficulty addressing needs. Human Resources The ability to deliver high-quality trauma care is highly dependent on the availability of skilled human resources. Therefore, it is critical to assess the availability and educational needs of providers on a periodic basis. Because availability, particularly of subspecialty resources, is often limited, some means of addressing recruitment, retention, and engagement of qualified personnel should be a priority. Periodic workforce assessments should be conducted. Maintenance of competence should be ensured by requiring standards for credentialing and certification and specifying continuing educational requirements for physicians and nurses providing care to trauma patients. Mechanisms for the periodic assessment of ancillary and subspecialty competence, educational needs, and availability within the system for all designated facilities should be incorporated into the trauma system plan. The lead trauma centers in rural areas will need to consider teleconferencing and telemedicine to assist smaller facilities in providing education on regionally identified needs. In addition, lead trauma centers within the region should assist in meeting educational needs while fostering a team approach to care through annual educational multidisciplinary trauma conferences. These activities will do much to foster a sense of teamwork and a functionally inclusive system. Integration of Designated Trauma Facilities Within the Trauma System Designated trauma facilities must be well integrated into all other facets of an organized system of trauma care, including public health systems and injury surveillance, prevention, EMS and prehospital care, disaster preparedness, rehabilitation, and system performance improvement. This integration should be provided by the state and/or regional trauma plan and overseen by the lead agency. Each designated acute care facility should participate, through its trauma program leadership, in all aspects of trauma system design, evaluation, and operation. This participation should include policy and legislative development, legislative and public education, and strategic planning. In addition, the trauma program and subspecialty leaders should provide direction and oversight to the development, implementation, and monitoring of integrated protocols for patient care used throughout the system (for example, TBI guidelines used by prehospital providers and nondesignated transferring centers), including region specific primary (field) and secondary (early transfer) triage protocols. The highest level trauma facilities should provide leadership of the regional 54

trauma committees through their trauma program medical leadership. These medical leaders, through their activities on these committees, can assist the lead agency and help ensure that deficiencies in the quality of care within the system, relative to national standards, are recognized and corrected. Educational outreach by these higher levels centers should be used when appropriate to help achieve this goal. Optimal Elements I. Acute care facilities are integrated into a resource efficient, inclusive network that meets required standards and that provides optimal care for all injured patients. (B-303) a. The trauma system plan has clearly defined the roles and responsibilities of all acute care facilities treating trauma and of facilities that provide care to specialty populations (for example, burn, pediatric, SCI, and others). (I-303.1) II. To maintain its state, regional, or local designation, each hospital will continually work to improve the trauma care as measured by patient outcomes. (B-307) a. The trauma system engages in regular evaluation of all licensed acute care facilities that provide trauma care to trauma patients and of designated trauma hospitals. Such evaluation involves independent external reviews. (I-307.1) III. The lead trauma authority ensures a competent workforce. (B-310) a. As part of the established standards, set appropriate levels of trauma training for nursing personnel who routinely care for trauma patients in acute care facilities. (I-310.3) b. Ensure that appropriate, approved trauma training courses are provided for nursing personnel on a regular basis. (I-310.4) c. In cooperation with the nursing licensure authority, ensure that all nursing personnel who routinely provide care to trauma patients have a trauma training certificate (for example, Advanced Trauma Care for Nurses, Trauma Nursing Core Course, or any national or state trauma nurse verification course). As an alternative after initial trauma course completion, training can be driven by the performance improvement process. (I-310.5) d. In cooperation with the physician licensure authority, ensure that physicians who routinely provide care to trauma patients have a current trauma training certificate of completion, for example, Advanced Trauma Life Support® (ATLS®) and others. As an alternative, physicians may maintain trauma competence through continuing medical education programs after initial ATLS completion. (I310.8) e. Conduct at least 1 multidisciplinary trauma conference annually that encourages system and team approaches to trauma care. (I-310.9)

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f. As new protocols and treatment approaches are instituted within the system, structured mechanisms are in place to inform all personnel about the changes in a timely manner. (I-310-10) Current Status The South Carolina trauma system designates facilities as trauma centers through two pathways. A facility may choose to be assessed by the ACS-COT for compliance with the verification standards in the Resources for the Optimal Care of the Injured Patient. Alternatively, a facility can choose to be designated against state developed criteria, which are based loosely on the ACS-COT criteria and significantly weakened. The effect is that trauma centers designated at the same level are not meeting similar standards. Allowing different standards within a given designation level creates the potential for unequal levels of care, and it may also create challenges in the public’s ability to compare facilities. South Carolina recognizes participation at three levels in the trauma system (Levels I, II, and III). Designation is for a maximum period of five (5) years, but it may be for fewer years depending on the number and type of deficiencies identified at the survey or the interval for ACS-COT re-verification review. The state has 16 designated trauma centers -- four are Level I, three are Level II, and nine are Level III. Two of the Level I trauma centers and one of the Level II trauma centers are verified by the ACS-COT. None of the Level III trauma centers is verified by the ACS-COT. Distribution of designated trauma centers across the state is in concordance with population density and geographic features. Specialty trauma care centers do not play a major role in the state. No American Burn Association verified burn center exists in the state, but a referral burn center is located in Augusta, GA. Only two trauma centers in the state provide burn care, one of which limits care to outpatients, and the other does some pediatric burn care. No rehabilitation centers for spinal cord injury exist in the state. The trauma system functions as an exclusive system although some interest in the involvement of non-designated facilities is emerging. South Carolina’s trauma leaders recognize that non-designated facilities play a critical role in the initial resuscitation of injured patients in many areas of the state. As no data are collected from all facilities, some essential information about the trauma system is not known:  The number of injured patients who arrive at or are transported to nondesignated facilities  The number of injured patients who meet criteria for care at a trauma center but remain in a non-designated facility for their full hospital stay Currently, designated trauma centers have no requirement to have transfer agreements with any outlying hospital (e.g., non-designated hospitals and a lower level designated trauma center). Some outreach is made to the non-designated facilities by trauma 56

centers within the same region, but this is not well organized from a system perspective or evaluated in any manner. The state’s designated trauma centers currently appear well distributed, but this appears to be a fortunate occurrence not due to planning. The trauma system has no provisions in its designation process that assess needs of the population or the trauma system when considering facility applications. While stakeholders do not identify any current concerns about the number of trauma centers in the trauma system or their distribution, population growth or changing healthcare system dynamics may place a greater importance on a needs assessment process as part of the designation criteria. Recommendations 

Adopt the designation criteria specified in the most current version of the American College of Surgeons Committee on Trauma (ACS-COT) Resources for the Optimal Care of the Injured Patient.



Consider using the ACS-COT Verification, Review, and Consultation process to optimize resource utilization within the lead agency.



Require all acute care facilities to participate in the inclusive and integrated trauma system as a condition of licensure. o Designate each acute care facility at an appropriate level, either as a trauma center or a participating facility.



Assess opportunities to establish a needs-based criterion for designation.



Establish requirements for inter-facility transfer agreements.

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System Coordination and Patient Flow Purpose and Rationale To achieve the best possible outcomes, the system must be designed so that the right patient is transported to the right facility at the right time. Although on the surface this objective seems relatively straightforward, patients, geography, and transportation systems often conspire to present significant challenges. The most critically injured trauma patient is often easy to identify at the scene by virtue of the presence of coma or hypotension. However, in some circumstances, the patients requiring the resources of a Level I or II center may not be immediately apparent to prehospital providers. Primary or field triage criteria aid providers in identifying which patients have the greatest likelihood of adverse outcomes and might benefit from the resources of a designated trauma center. Even if the need is identified, regional geography or limited air medical (or land) transport services might not allow for direct transport to an appropriate facility. Primary triage of a patient from the field to a center capable of providing definitive care is the goal of the trauma system. However, there are circumstances (for example, airway management, rural environments, inclement weather) when triaging a patient to a closer facility for stabilization and transfer is the best option for accessing definitive care. Patients sustaining severe injuries in rural environments might need immediate assessment and stabilization before a long-distance transport to a trauma center. In addition, evaluation of the patient might bring to light severe injuries for which needed care exceeds the resources of the initial receiving facility. Some patients might have specific needs that can be addressed at relatively few centers within a region (for example, pediatric trauma, burns, severe TBI, SCI, and reimplantation). Finally, temporary resource limitations might necessitate the transfer of patients between acute care facilities. Secondary triage at the initial receiving facility has several advantages in systems with a large rural or suburban component. The ability to assess patients at nondesignated or Level III to V centers provides an opportunity to limit the transfer of only the most severely injured patients to Level I or II facilities, thus preserving a limited resource for patients most in need. It also provides patients with lesser injuries the possibility of being cared for within their community. The decision to transfer a trauma patient should be based on objective, prospectively agreed-on criteria. Established transfer criteria and transfer agreements will minimize discussions about individual patient transfers, expedite the process, and ensure optimal patient care. Delays in transfer might increase mortality, complications, and length of stay. A system with an excess of transferred patients might tax the resources of the regional trauma facility. Conversely, inappropriate retention of patients at centers without adequate facilities or expertise might increase the risk of adverse outcomes. Given the importance of timely, appropriate interfacility transfers, the time to transfer, as well as the rates of primary and secondary overtriage basis, and corrective actions should be instituted when problems are identified. Data derived from tracking and 58

monitoring the timeliness of access to a level of trauma care commensurate with injury type and severity should be used to help define optimal system configuration. A central communications center with real-time access to information on system resources greatly facilitates the transfer process. Ideally, this center identifies a receiving facility, facilitates dialogue between the transferring and receiving centers, and coordinates interfacility transport. To ensure that the system operates at the greatest efficiency, it is important that patients are repatriated back to community hospitals once the acute phase of trauma care is complete. The process of repatriation opens up the limited resources available to care for severely injured patients. In addition, it provides an opportunity to bring patients back into their local environment where their social network might help reintegrate patients into their community. Optimal Elements I. The trauma system is supported by an EMS system that includes communications, medical oversight, prehospital triage, and transportation; the trauma system, EMS system, and public health agency are well integrated. (B-302) a. There are mandatory system-wide prehospital triage criteria to ensure that trauma patients are transported to an appropriate facility based on their injuries. These triage criteria are regularly evaluated and updated to ensure acceptable and system-defined rates of sensitivity and specificity for appropriately identifying a major trauma patient. (I-302.6) b. There is a universal access number for citizens to access the EMS/trauma system, with dispatch of appropriate medical resources. There is a central communications system for the EMS/trauma system to ensure field-to- facility bidirectional communications, interfacility dialogue, and all-hazards response communications among all system participants. (I-302.7) c. There is a procedure for communications among medical facilities when arranging for interfacility transfers, including contingencies for radio or telephone system failure. (I-302.9) II. Acute care facilities are integrated into a resource-efficient, inclusive network that meets required standards and that provides optimal care for all injured patients. (B-303) a. When injured patients arrive at a medical facility that cannot provide the appropriate level of definitive care, there is an organized and regularly monitored system to ensure that the patients are expeditiously transferred to the appropriate system-defined trauma facility. (I-303.4) Current Status A statewide standard field trauma triage protocol is in place and serves as a guideline for ground EMS agencies regarding field transport destination decisions. Since each 59

EMS agency, by statute, must have a physician EMS medical director, the state allows latitude in the use of this protocol. However, the degree to which compliance with this guideline is monitored is unknown. It is not known if the air medical providers utilize this guideline to determine trauma destinations. The state has no defined interfacility transfer criteria for the movement of trauma patients from the non-designated hospitals to trauma centers. It is not known how this affects the timeliness of transfer. Individual trauma centers report occasional delays in patient transfer. Level I trauma centers report they routinely monitor and provide feedback to their local ground EMS agencies. This feedback encompasses destination decisions as well as patient outcomes data. These trauma centers additionally provide outreach by way of education and feedback to facilities that transfer trauma patients to them. The TSC team perceived a spirit of cooperation and collegiality has been built at the local level between the major trauma centers, the EMS agencies, and nondesignated facilities in their catchment area. The Division of EMS and Trauma leadership reported that no process for overseeing or monitoring patient flow at any level exists. Plans were described to develop regional trauma councils which may provide assistance for this important function. At this time, the trauma system is unable to report the over- or under-triage rate for trauma patients. The state’s monitoring and oversight functions are further hampered since the nondesignated hospitals are not comprehensively included in the trauma system plan. System stakeholders report the biggest barrier to patient movement is in the area of rehabilitation. The trauma centers identified rehabilitation as the “bottleneck” in the care system for the trauma patient. Trauma center leaders described the challenge of obtaining the needed outpatient rehabilitation care for patients that resulted in increased trauma center length of stay. The frequency and magnitude of this challenge are not known, since the issue is not tracked within the trauma system. Recommendations 

Develop interfacility transfer guidelines to ensure the timely identification and safe transfer of trauma patients.



Establish metrics to track the patient flow through the trauma system from the time of injury to the return to work. o Consider the following metrics: time of injury, scene time, destination decision, over/under-triage rates, time to transfer, length of emergency department stay, time to the operating room, hospital length of stay, delay in hospital discharge, rehabilitation days. o Monitor priority metrics over a defined time frame and benchmark state data against national standards. o Refine system metrics as the system matures. 60

Rehabilitation Purpose and Rationale As an integral component of the trauma system, rehabilitation services in acute care and rehabilitation centers provide coordinated care for trauma patients who have sustained severe or catastrophic injuries, resulting in long-standing or permanent impairments. Patients with less severe injuries may also benefit from rehabilitative programs that enhance recovery and speed return to function and productivity. The goal of rehabilitative interventions is to allow the patient to return to the highest level of function, reducing disability and avoiding handicap whenever possible. The rehabilitation process should begin in the acute care facility as soon as possible, ideally within the first 24 hours. Inpatient and outpatient rehabilitation services should be available. Rehabilitation centers should have CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation for comprehensive inpatient rehabilitation programs, and accreditation of specialty centers (SCI and TBI) should be strongly encouraged. The trauma system should conduct a rehabilitation needs assessment (including specialized programs in SCI, TBI, and for children) to identify the number of beds needed and available for rehabilitation in the geographic region. Rehabilitation specialists should be integrated into the multidisciplinary advisory committee to ensure that rehabilitation issues are integrated into the trauma system plan. The trauma system should demonstrate strong linkages and transfer agreements between designated trauma centers and rehabilitation facilities located in its geographic region (in or out of state). Plans for repatriation of patients, especially when rehabilitation centers across state lines are used, should be part of rehabilitation system planning. Feedback on functional outcomes after rehabilitation should be made available to the trauma centers. Optimal Elements I. The lead agency ensures that adequate rehabilitation facilities have been integrated into the trauma system and that these resources are made available to all populations requiring them. (B-308) a. The lead agency has incorporated, within the trauma system plan and the trauma center standards, requirements for rehabilitation services, including interfacility transfer of trauma patients to rehabilitation centers. (I-308.1) b. Rehabilitation centers and outpatient rehabilitation services provide data on trauma patients to the central trauma system registry that include final disposition, functional outcome, and rehabilitation costs and also participate in performance improvement processes. (I-308.2) II. A resource assessment for the trauma system has been completed and is regularly updated. (B-103) 61

a. The trauma system has completed a comprehensive system status inventory that identifies the availability and distribution of current capabilities and resources. (I103.1) Current Status South Carolina trauma centers refer to three rehabilitation centers that have achieved Commission on Accreditation of Rehabilitation Facilities (CARF) international accreditation, two of which are located in other states. Some trauma patients are transferred to these facilities. At the time of the TSC visit, no information was available regarding the number of rehabilitation beds in the state. A shortage of rehabilitation beds was reported, as well as difficulty in placement for under-insured and uninsured trauma patients. The trauma system has not completed an assessment of rehabilitation capabilities. No statewide performance improvement (PI) focused audit to determine the magnitude of the trauma rehabilitation issues has been initiated to identify preventable extended hospital length of stay. The TAC has one formal rehabilitation representative, and a second member provides disability services. The participation of these individuals is variable, and it is not known if these representatives provide two-way communication from their professional associates to the TAC membership. The revitalized TAC does not yet appear to have had much focus on rehabilitation issues. Efforts to revitalize rehabilitation integration into the state trauma system could include the appointment of a subcommittee and activities such as face-to-face meetings with rehabilitation leadership from throughout the state. Meeting agenda items could potentially include an inventory of rehabilitation services available, PI opportunities, data opportunities, and plans to maintain open communications. The TASC and other TAC leadership could potentially take the lead in the proposed face to face meetings with rehabilitation leadership. The TASC has introduced a focus on rehabilitation. Speakers have been invited to address rehabilitation issues at their annual symposium. One rehabilitation data repository exists for the state spinal cord injury/traumatic brain injury (SCI-TBI) program, and reports are available. These data could be used to augment trauma system PI efforts. Data linkages between the state trauma registry and the SCI-TBI data repository do not exist, but such a linkage would be valuable. While it can be challenging to identify specific rehabilitation data elements that should be collected at the trauma center level, the TAC’s Data and PI Subcommittee should consider developing a minimal data set in collaboration with rehabilitation leadership. The trauma system reported that no treatment guidelines exist for rehabilitation. The trauma system also has no mechanisms in place to ensure or encourage rehabilitation integration.

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Recommendations 

Complete a needs assessment and gap analysis of rehabilitation capabilities and capacity across the state.



Implement a statewide performance improvement project to define the magnitude of the problem regarding delays in access to rehabilitation. o Implement an avoidable length of stay focused audit for the trauma centers to quantify delays in transfer to a rehabilitation facility. o Complete a focused audit of the findings at 12 months. o Present results to trauma and rehabilitation leadership. o Identify corrective strategies, implement, and re-evaluate.



Conduct face-to-face meetings between trauma and rehabilitation leadership to identify opportunities and solutions to trauma patient rehabilitation.



Create data linkages with the state rehabilitation databases and the state trauma registry.

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Disaster Preparedness Purpose and Rationale As critically important resources for state, regional, and local responses to MCIs, the trauma system and its trauma centers are central to disaster preparedness. Trauma system leaders need to be actively involved in public health preparedness planning to ensure that trauma system resources are integrated into the state, regional, and local disaster response plans. Acute care facilities (sometimes including one or more trauma centers) within an affected community are the first line of response to an MCI. However, an MCI may result in more casualties than the local acute care facilities can handle, requiring the activation of a larger emergency response plan with support provided by state and regional assets. For this reason, the trauma system and its trauma centers must conduct a resource assessment of its surge capacity to respond to MCIs. The resource assessment should build on and be coupled to a hazard vulnerability analysis. An assessment of the trauma system’s response to simulated incident or tabletop drills must be conducted to determine the trauma system’s ability to respond to MCIs. Following these assessments, a gap analysis should be conducted to develop statewide MCI response resource standards. This information is essential for the development of an emergency management plan that includes the trauma system. Planning and integration of the trauma system with plans of related systems (public health, EMS, and emergency management) are important because of the extensive impact disasters have on the trauma system and the value of the trauma system in providing care. Relationships and working cooperation between the trauma system and public health, EMS, and emergency management agencies support the provision of assets that enable a more rapid and organized disaster response when an event occurs. For example, the EMS emergency preparedness plan needs to include the distribution of severely injured patients to trauma centers, when possible, to make optimal use of trauma center resources. This plan could optimize triage through directing less severely injured patients to lower level trauma centers or nondesignated facilities, thus allowing resources in trauma centers to be spared for patients with the most severe injuries. In addition, the trauma system and its trauma centers will be targeted to receive additional resources (personnel, equipment, and supplies) during major MCIs. Mass casualty events and disasters are chaotic, and only with planning and drills will a more organized response be possible. Simulation or tabletop drills provide an opportunity to test the emergency preparedness response plans for the trauma system and other systems and to train the teams that will respond. Exercises must be jointly conducted with other agencies to ensure that all aspects of the response plan have the trauma system integrated.

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Optimal Elements I. An assessment of the trauma system’s emergency preparedness has been completed, including coordination with the public health agency, EMS system, and the emergency management agency. (B-104) a. There is a resource assessment of the trauma system’s ability to expand its capacity to respond to MCIs in an all-hazards approach. (I-104.1) b. There has been a consultation by external experts to assist in identifying current status and needs of the trauma system to be able to respond to MCIs. (I-104.2) c. The trauma system has completed a gap analysis based on the resource assessment for trauma emergency preparedness. (I-104.3) II. The lead agency ensures that its trauma system plan is integrated with, and complementary to, the comprehensive mass casualty plan for natural and manmade incidents, including an all-hazards approach to planning and operations. (B-305) a. The EMS, the trauma system, and the all-hazards medical response system have operational trauma and all-hazards response plans and have established an ongoing cooperative working relationship to ensure trauma system readiness for all-hazards events. (I-305.1) b. All-hazards events routinely include situations involving natural (for example, earthquake), unintentional (for example, school bus crash), and intentional (for example, terrorist explosion) trauma-producing events that test the expanded response capabilities and surge capacity of the trauma system. (I-305-2) c. The trauma system, through the lead agency, has access to additional equipment, materials, and personnel for large-scale traumatic events. 305.3)

(I-

Current Status The Director of EMS, state TPM, and the EMS program manager are designated Division of EMS and Trauma representatives to the state emergency operations center (EOC) in support of Emergency Support Function (ESF) 8 (Health and Medical). In this capacity, they are an immediate resource to state, regional, and local emergency managers during an event. The Office of Public Health Preparedness has an established line of reporting to the Director of the DHEC, which is at least six positions higher on the DHEC organization chart above the EMS and trauma programs. This leads to a significant disconnection between the trauma and emergency preparedness programs, and the TSC team could not determine whether any coordination is fostered between these programs. It was reported that a disaster preparedness assessment may have been completed in 2013 under the direction of the Office Public Health Preparedness, but this assessment was not made available to the current TPM or for review by the TSC team. 65

The trauma centers did report some active engagement in regional emergency operation plans. The TSC team could not determine if this was a standard practice or to what extent this was occurring statewide. No evidence was provided that the trauma system and the trauma centers were consulted for input and inclusion in the statewide emergency operations plan that addresses medical surge capacity and multiple casualties. One trauma surgeon stated that the surgeons and medical staff are often excluded from the emergency and disaster discussions within their own hospitals. The state has established a web-based tracking system to monitor surge in personnel, equipment, and supplies to include available beds and capabilities. The State Medical Asset Resource Tracking Tool (SMARTT), when updated by the local medical facility, can serve as a valuable resource to monitor statewide medical resources during a disaster or public health emergency. The local EMS providers and trauma center TPMs have access to SMARTT in real time. However, the TSC team perceived that little attention had been paid by the state TPM, the TASC, or the TAC regarding how the SMARTT could be used for the benefit of the EMS and trauma system planning, e.g., destination guidelines or data regarding times trauma centers are on diversion. A disaster or public health emergency can have a devastating impact upon trauma centers and the dedicated staff serving them. However, the TSC team could not determine to what extent funding and support has been allocated to the trauma centers to offset their planning and preparedness activities. The state EMS program has access to a statewide 800MHz radio system to improve communication during disasters. The various trauma stakeholders did not indicate knowledge of such capability. Recommendations 

Ensure that trauma stakeholders participate in formal statewide emergency operations plan (EOP) assessments.



Ensure that high level trauma representatives are included in state level assessments and exercises and provide reports back to trauma stakeholders.



Integrate a trauma surgeon representing the South Carolina Trauma Advisory Council into the EOP planning leadership.



Support the continuous development, routine use, and evaluation of the State Medical Asset Resource Tracking Tool (SMARTT) by the trauma system.



Develop a statewide unified communications system that also includes early notification of trauma centers during a disaster.

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Systemwide Evaluation and Quality Assurance Purpose and Rationale The trauma lead agency has responsibility for instituting processes to evaluate the performance of all aspects of the trauma system. Key aspects of system-wide effectiveness include the outcomes of population based injury prevention initiatives, access to care, as well as the availability of services, the quality of services provided within the trauma care continuum from prehospital and acute care management phases through rehabilitation and community reintegration, and financial impact or cost. Intrinsic to this function is the delineation of valid, objective metrics for the ongoing quality audit of system performance and patient outcomes based on sound benchmarks and available clinical evidence. Trauma management information systems (MISs) must be available to support data collection and analysis. The lead agency should establish forums that promote inclusive multidisciplinary and multiagency review of cases, events, concerns, regulatory issues, policies, procedures, and standards that pertain to the trauma system. The evaluation of system effectiveness must take into account the integration of these various components of the trauma care continuum and review how well personnel, agencies, and facilities perform together to achieve the desired goals and objectives. Results of customer satisfaction (patient, provider, and facility) appraisals and data indicative of community and population needs should be considered in strategic planning for system development. System improvements derived through evaluation and quality assurance activities may encompass enhancements in technology, legislative or regulatory infrastructure, clinical care, and critical resource availability. To promote participation and sustainability, the lead agency should associate accountability for achieving defined goals and trauma system performance indicators with meaningful incentives that will act to cement the support of key constituents in the health care community and general population. For example, the costs and benefits of the trauma system as they relate to reducing mortality or decreasing years of productive life lost may make the value of promoting trauma system development more tangible. A facility that achieves trauma center verification/designation may be rewarded with monetary compensation (for example, ability to bill for trauma activation fees) and the ability to serve as a receiving center for trauma patients. The trauma lead agency should promote ongoing dialog with key stakeholders to ensure that incentives remain aligned with system needs. Optimal Elements I. The trauma MIS is used to facilitate ongoing assessment and assurance of system performance and outcomes and provides a basis for continuously improving the trauma system, including a cost-benefit analysis. (B-301) 67

a. The lead trauma authority ensures that each member hospital of the trauma system collects and uses patient data, as well as provider data, to assess system performance and to improve quality of care. Assessment data are routinely submitted to the lead trauma authority. (I-301.1) II. The jurisdictional lead agency, in cooperation with other agencies and organizations, uses analytic tools to monitor the performance of population based prevention and trauma care services. (B-304) III. The financial aspects of the trauma system are integrated into the overall performance improvement system to ensure ongoing fine tuning and cost-effectiveness. (B-309) a. Financial data are combined with other cost, outcome, or surrogate measures, for example, years of potential life lost, quality-adjusted life years, and disability adjusted life years; length of stay; length of intensive care unit stay; number of ventilator days; and others, to estimate and track true system costs and costbenefits. (I-309.4) Current Status A strong interest in implementing a trauma system performance improvement (PI) process on a formalized statewide basis was stated during the TSC visit. The Data and PI subcommittee was recently created under the auspices of the TAC, and it has an enthusiastic and committed membership. The members consist of trauma center TPM’s and trauma registrars from various trauma centers, and at least one representative from the TAC. The subcommittee is chaired by one of the trauma medical directors who appeared to be quite knowledgeable about the concepts of trauma data and PI. The Data and PI subcommittee has met twice. A review of the meeting minutes revealed that the committee agenda items and discussions are appropriately focused. At the first meeting, the subcommittee identified 7 goals:       

Establish objective criteria for review of state certified trauma centers Review and define data points submitted to the state trauma registry including complications Develop quarterly reports from the state trauma registry Develop a process for South Carolina State PI Develop a validation model for the state trauma registry Explore combining the EMS and state trauma registry Explore real-time submission of data to the state trauma registry

These goals appear to be appropriately targeted given the current status of the state trauma system. As the trauma system develops and these goals are attained, adjustments will be needed to keep the subcommittees goals dynamic rather than static. To do this, the data and PI subcommittee needs to have a strategic plan that includes objectives, work teams, project leads, and deadlines. 68

The subcommittee members and goals reflect the natural fit of combining data with PI. However, multiple issues exist with the state trauma system registry. Discussions regarding trauma registry data can be detailed and lengthy and postpone any movement toward actual systemwide PI to the point that it never gets initiated. Consideration should be given to breaking out these two focus areas and creating a subcommittee for each. Close interface would need to occur between these groups to prevent silos. It was reported that the trauma centers have not been able to submit data to the state trauma system registry. The issue identified was that the bridge to version 5 of Digital Innovations software has not been completed due to challenges within the DHEC Information Technology (IT) department responsible for this project, causing significant delays. It was reported that the state trauma registry software update would be completed within a few days of the TSC visit, but the state trauma registry would probably not be able to accept data until July 2014. At that point, the participating trauma centers will be notified to upload their data. Following this upload, the Division of EMS and Trauma staff reported they would need an additional 6 months to validate the data. These delays are seriously detrimental to the trauma system. Aggressive measures should be taken to prevent future system trauma registry issues. These measures include augmenting the current Division of EMS and Trauma staff with 1.0 FTE trauma registrar, protocols or guidelines for software and hardware preventative maintenance, timely IT support, proactive discussions and planning for trauma data and registry technical support, and providing routine status reports to the TAC Data and PI Subcommittee. Currently, the trauma centers are collecting and submitting trauma registry data. The non-designated facilities do not participate in any form of trauma data collection. This lack of data hinders the trauma system PI process. Leadership should make every effort to bring the non-designated facilities into the system. The Level I and II trauma centers conduct trauma PI within their own facilities. It was reported that the Level I trauma centers participate in the ACS-COT Trauma Quality Improvement Program (TQIP). Some preliminary discussions about using TQIP for the trauma system have occurred. In the absence of a functional state trauma registry data validation process, all Level I and II trauma centers are encouraged to join the TQIP program in order to begin processes of data validation. The non-designated facilities are not directly involved in trauma PI outside of their immediate catchment areas. The Level I and II trauma centers embrace the hospitals that transfer trauma patients to them and include them in PI processes as needed. Examples reported are follow-up information letters, direct communications discussing specific cases that have PI issues identified, and educational endeavors as part of corrective action. Within the Division of EMS and Trauma, no systemwide trauma PI is being conducted, and the state TPM does not have the time to perform this function with assigned 69

responsibilities. A full-time trauma PI coordinator is needed to support statewide trauma PI initiatives. Several identified state trauma registry issues currently restrict the PI process. Waiting for concurrent and validated data from the state trauma registry could potentially stifle the momentum and enthusiasm of the TAC Data and PI Subcommittee. On an interim basis, alternate data sources could be used. The PI indicators could be developed based on the available data sources, such as the EMS database or the hospital discharge data set. These data sources could be used to examine issues such as overand under- triage, prehospital trauma triage destination, and interfacility transfers. Trauma center leadership expressed significant concern regarding confidentiality of the trauma registry data, reports, and PI activity. To date, the TAC has not solicited a legal opinion from the DHEC Legal Department or the State Attorney General regarding the current law as it pertains to confidentiality of data, and peer review protection. A legal opinion should be sought to determine if action is needed. The trauma system program was reported to have a PI toolkit that needs updating. It was not determined if this toolkit is specific to South Carolina’s trauma system or if it is a generic template. Regardless, this toolkit should be reviewed, revised, and customized to fit the needs of the state’s trauma system. It was acknowledged that this would be a valuable tool for current and new trauma center personnel. Mentoring, continued education, and peer support specific to trauma PI is done through the TASC. An attempt to implement a component of statewide PI in the format of case presentations (a form of system mortality – morbidity conferences) via teleconference was reported. While time and effort went into the planning phase, it was reported that the process was not initiated due to uncertainty regarding peer review protection, lack of funding for teleconferencing support, and lack of technology in some of the hospitals. The trauma system and trauma center leadership should embark upon a process to adjust the general concepts of this initial plan. Offering statewide trauma educational grand rounds is a viable concept. General principles for content could potentially include cases that involve interfacility transfers, multiple casualty incidents, special populations, seasonal challenges with air versus ground transports, and burn patients with associated traumatic injuries. These case presentations would need to be de-identified to the point of alleviating any current concerns regarding breach of confidentiality, while assuring the educational points are featured. Removing educational delivery barriers could include the use of simple electronic methods such as webinars for single PC or multiple participants. Recommendations 

Develop a trauma performance improvement (PI) toolkit for new trauma program managers, trauma PI personnel, trauma medical directors, and other trauma center and trauma system staff. o Post these toolkits on both the state trauma and TASC websites. 70

o Ensure that the toolkit includes content for both trauma center and regional/statewide PI. 

Separate the Trauma Advisory Council Data and PI Subcommittee into two separate subcommittees with distinct strategic goals and objectives for each.



Develop a list of trauma system PI indicators.



Select two indicators for trauma system PI, and using existing available data sources (e.g. preMIS), start the PI cycle now.



Hire a trauma system PI coordinator (1.0 FTE) to report directly to the state trauma program manager and the TAC. o Ensure a comprehensive and appropriate job description.



Implement statewide and/or regional trauma grand rounds as one aspect of the systemwide PI processes. o Present blinded cases that impact or highlight relevant PI opportunities. o Establish teleconferencing capability to deliver these grand rounds or alternatively use a web-based delivery model. o Identify philanthropic sources for financial support of technology expenses, e.g., Office of Rural Health Policy.



Consider implementing the American College of Surgeons’ Trauma Quality Improvement Program (TQIP) on a systemwide level. o Identify stable sources for financial support. o Include the Level III hospitals when the ACS encourages these trauma centers to participate.

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Trauma Management Information Systems Purpose and Rationale Hospital-based trauma registries developed from the idea that aggregating data from similar cases may reveal variations in care and ultimately result in a better understanding of the underlying injury and its treatment. Hospital-based registries have proven very effective in improving trauma care within an institution but provide limited information regarding how interactions with other phases of health care influence the outcome of an injured patient. To address this limitation, data from hospital-based registries should be collated into a regional registry and linked such that data from all phases of care (prehospital, hospital, and rehabilitation) are accessible in 1 data set. When possible, these data should be further linked to law enforcement, crash incident reports, ED records, administrative discharge data, medical examiner records, vital statistics data (death certificates), and financial data. The information system should be designed to provide system-wide data that allow and facilitate evaluation of the structure, process, and outcomes of the entire system; all phases of care; and their interactions. This information should be used to develop, implement, and influence public policy. The lead agency should maintain oversight of the information system. In doing so, it must define the roles and responsibilities for agencies and institutions regarding data collection and outline processes to evaluate the quality, timeliness, and completeness of data. There must be some means to ensure patient and provider confidentiality is in keeping with federal regulations. The agency must also develop policies and procedures to facilitate and encourage injury surveillance and trauma care research using data derived from the trauma MIS. There are key features of regional trauma MISs that enhance their usefulness as a means to evaluate the quality of care provided within a system. Patient information collected within the management system must be standardized to ensure that noted variations in care can be characterized in a similar manner across differing geographic regions, facilities, and EMS agencies. The composition of patients and injuries included in local registries (inclusion criteria) should be consistent across centers, allowing for the evaluation of processes and outcomes among similar patient groups. Many regions limit their information systems to trauma centers. However, the optimal approach is to collect data from all acute care facilities within the region. Limiting required data submission to hospitals designated as trauma centers allows one to evaluate systems issues only among patients transported to appropriate facilities. It is also important to have protocols in place to ensure a uniform approach to data abstraction and collection. Research suggests that if the process of case abstraction is not routinely calibrated, practices used by abstractors begin to drift. Finally, every effort should be made to conform to national standards defining processes for case acquisition, case definition (that is, inclusion criteria), and registry coding conventions. Two such national standards include the National Highway Traffic Safety Administration’s National Emergency Medical Services Information System (NEMSIS), which standardizes EMS data collection, and the American College of 72

Surgeons National Trauma Data Standard, which addresses the standardization of hospital registry data collection. Strictly adhering to national standards markedly increases the value of state trauma MISs by providing national benchmarks and allowing for the use of software solutions that link data sets to enable a review of the entire injury and health care event for an injured patient. To derive value from the tremendous amount of effort that goes into data collection, it is important that a similar focus address the process of data reporting. Dedicated staff and resources should be available to ensure rapid and consistent reporting of information to vested parties with the authority and vision to prevent injuries and improve the care of patients with injuries. An optimal information reporting process will include standardized reporting tools that allow for the assessment of temporal and/or system changes and a dynamic reporting tool, permitting anyone to tailor specific “views” of the information. Optimal Elements I. There is an established trauma MIS for ongoing injury surveillance and system performance assessment. (B-102) a. There is an established injury surveillance process that can, in part, be used as an MIS performance measure. (I-102.1) b. Injury surveillance is coordinated with statewide and local community health surveillance. (I-102.2) c. There is a process to evaluate the quality, timeliness, completeness, and confidentiality of data. (I-102.4) d. There is an established method of collecting trauma financial data from all health care facilities and trauma agencies, including patient charges and administrative and system costs. (I-102.5) II. The trauma MIS is used to facilitate ongoing assessment and assurance of system performance and outcomes and provides a basis for continuously improving the trauma system, including a cost-benefit analysis. (B-301) a. The lead trauma authority ensures that each member hospital of the trauma system collects and uses patient data, as well as provider data, to assess system performance and to improve quality of care. Assessment data are routinely submitted to the lead trauma authority. (I-301.1) b. Prehospital care providers collect patient care and administrative data for each episode of care and not only provide these data to the hospital, but also have a mechanism to evaluate the data within their own agency, including monitoring trends and identifying outliers. (I-301.2) c. Trauma registry, ED, prehospital, rehabilitation, and other databases are linked or combined to create a trauma system registry. (I-301.3)

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d. The lead agency has available for use the latest in computer/technology advances and analytic tools for monitoring injury prevention and control components of the trauma system. There is reporting on the outcome of implemented strategies for injury prevention and control programs within the trauma system. (I-301.4) Current Status South Carolina has a wealth of data pertaining to mechanism of injury, prehospital care, acute trauma care, and mortality. Unfortunately, the data are housed in various locations and have not been well integrated or linked to provide a complete picture of the burden of injury and/or the response to injury across the state. The prehospital data set, South Carolina PreMIS, is quite mature. It is inextricably linked to the North Carolina version and is supported by the same technical assistance center. PreMIS was initially developed by a grant from the Duke Endowment, the National Highway Traffic Safety Administration, and state level resources with the data housed on a secure server in North Carolina. Standard reports are accessible on-line and customized reporting is available. Data submission is required from all licensed transporting EMS agencies in South Carolina. Data must be submitted within 90 days of completing each patient contact. Trauma data are collected at each designated trauma center in South Carolina as a requirement of designation. The dominant local trauma registry software used by 14 of the 16 trauma centers is Digital Innovations, version 5. The state trauma registry also uses a Digital Innovations platform, but at the time of the TSC, the state was using version 4, which is incompatible with version 5 used by the trauma centers. An imminent upgrade to version 5 was reported. As a result, trauma center data are not being uploaded to the state trauma registry. The Division of EMS and Trauma’s data manager spends approximately 20% of his time on trauma-related duties. The latest state trauma reports provided to the TSC team were for the period of July 1, 2012 – June 30, 2013. The data manager reported a six month backlog of data to be validated, cleaned, and imported into the state registry. A Digital Innovations version upgrade to ensure compatibility is imminent, and it was predicted that the state trauma registry would be able to accept data beginning the latter part of June. It was suggested that the state trauma registry could be brought to concurrency within three months following the upgrade and troubleshooting. The data subcommittee of the TAC recently embarked on a revision of the South Carolina Trauma Registry data dictionary. This dictionary is closely aligned with the National Trauma Data Standard (NTDS) used by the ACS-COT’s National Trauma Data Bank (NTDB) and TQIP. The revision is nearing completion. Data validity/purity was also an expressed concern of the participants at the TSC visit. While there is likely acceptable inter-rater reliability within a single institution, it is unclear that such similarity exists between the trauma centers. While the availability of a single unified data dictionary promotes such consistency, it is not guaranteed. 74

Several other data sources exist including hospital and emergency department discharge data, vital records, spinal cord injury/traumatic brain injury, fire marshal, youth behavioral risk survey, rape crisis center, highway traffic safety data, and other disparate sources. Linkage of preMIS and other state trauma registries has occurred, including interface with the Digital Innovations product line. It was noted that once the South Carolina trauma registry version upgrade is completed, the linkage of South Carolina’s EMS and trauma data sets should be “relatively easy”. The cost of such linkage not known, but should be investigated for trauma system planning. Unfortunately, a lack of confidence in the confidentiality section of the EMS statute has hampered initiation of rigorous regional or state level trauma PI. This challenge is long standing, and it was noted in the EMS Assessment conducted by the National Highway Traffic Safety Administration in 1996. This mistrust in the statute is a key issue that must be reconciled to support and encourage systemwide PI. The issue is additionally discussed in the Statutory Authority and Systemwide Evaluation and Quality Improvement sections of this report. Recommendations 

Complete the version upgrade of the South Carolina state trauma registry as soon as possible.



Seek a legal review of the confidentiality section of the EMS statute (Section 4461-550) and associated regulation (R 61-116, 1004), along with other sections/regulations as needed, to confirm the confidentiality and discoverability protection for peer review to conduct EMS and Trauma Program systemwide performance improvement (see Statutory Authority section).



Identify funding to support linkage of the South Carolina preMIS and state trauma registry to support initial questions concerning the trauma system such as rates of over- and under-triage. o Complete such linkage as soon as the Digital Innovations Version 5 upgrade is completed.

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Identify opportunities and expertise to link the other important data resources to help describe the burden of injury, to determine injury prevention targets, and to evaluate the trauma system of South Carolina, including injury prevention efforts.

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Use all data sources to conduct systemwide performance improvement rather than relying only on the state trauma registry.

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Research Purpose and Rationale Overview of Research Activity Trauma systems are remarkably diverse. This diversity is simply a reflection of authorities tailoring the system to meet the needs of the region based on the unique combination of geographic, economic, and population characteristics within their jurisdiction. In addition, trauma systems are not fixed in their organization or operation. The system evolves over years in response to lessons learned, critical review, and changes in population demographics. Given the diversity of organization and the dynamic nature of any particular system, it is valuable when research can be conducted that evaluates the effectiveness of the regional or statewide system. Research drives the system and will provide the foundation for system development and performance improvement. Research findings provide value in defining best practices and might alter system development. Thus, the system should facilitate and encourage trauma-related research through processes designed to make data available to investigators. Competitive grants or contracts made available through lead authorities or constituencies should provide funds to support research activities. All system components should contribute to the research agenda. The extent to which research activities are required should be clearly outlined in the trauma system plan and/or the criteria for trauma center designation. The sources of data used for research might be institutional and regional trauma registries. As an alternative, population-based research might provide a broader view of trauma care within the region. Primary data collection, although desirable, is expensive but might provide insights into system performance that might not be otherwise available. Trauma Registry–based Research Investigators examining trauma systems can use the information recorded in trauma registries to great advantage to determine the prevalence and annual incidence rate of injuries, patterns of care that occur to injured patients in the system’s region, and outcomes for the patients. These data can be compared with standards available from other trauma registries, such as the NTDB. Such comparisons can then enable investigators to determine if care within their region is within standards and can allow for benchmarking. Initiating and sustaining injury prevention initiatives is a vital goal in mature trauma systems. Investigators can take a leadership role in performing research using trauma registry data that identify emerging threats and instituting public health measures to mitigate the threats. For example, a recent surge in death and disability related to off -road vehicles can be identified and the scope of the problem defined in terms of who, where, and how riders are injured, and then, through presentations and publications, the public can be informed of a new threat. 76

Trauma system administrators have a responsibility to control investigators’ access to the registry. The integrity and reliability of data in a trauma systems registry are essential if accurate research and valid conclusions are to be reached using the data. Trauma system administrators should have a process that screens data entered into the system’s composite registry from individual institutions. There should be a mechanism that ensures that the information is stored in a secure manner. Investigators who seek access to the trauma registry must follow a written policy and procedure that includes approval by an authorized institutional review board. Trauma registry data may include unique identifiers, and system administrators must ensure that patient confidentiality is respected, consistent with state and federal regulations. Population-based Trauma System Research A major disadvantage of using only trauma registry data to conduct research that evaluates injured patients in a region is the bias resulting from missing data on patients not treated at trauma centers. Specifically, most registry data are restricted to information from hospitals that participate in the trauma system. Although ideally all facilities participate in the form of an inclusive system, many systems do not attain this goal. Thus, a population-based data set provides investigators with the full spectrum of patients, irrespective of whether they have been treated in trauma centers or nondesignated centers or were never admitted to the hospital owing to death at the scene of incident or because their injuries were insufficiently severe to require admission. The state and national hospital discharge databases are examples of population-based data. These discharge databases contain information that was abstracted from medical records for billing purposes by hospital employees who enter these data into an electronic database. For investigators seeking a wider perspective on the care of injured patients in their region, these more inclusive data sets, compared with registries, are essential tools. Other population based data that may be of help include mortality vital statistics data recorded in death certificates. Selected regions might have outpatient data to capture patients who are assessed in the ED and then released. Investigators can use these population-based data to study the influence of a regional trauma system on the entire spectrum of patients within its catchment area. Participation in Research Projects and Primary Data Collection Multi-institutional research projects are important mechanisms for learning new knowledge that can guide the care of injured patients. Investigators within trauma systems can participate as coinvestigators in these projects. Investigators can participate by recruiting patients into prospective studies, being leaders in the design and administration of grants, and preparing manuscripts and reports. Evidence of this collaboration is that investigators within a trauma system are recognized in announcements of grants or awards. Lead agency personnel should identify and reach out to resources within the system with research expertise. These include academic centers and public health agencies. Measures of Research Activity 77

Research can be broadly defined as hypothesis-driven data analysis. This analysis leads the investigators to a conclusion, which might become a recommendation for system change. Full manuscripts published in peer reviewed research journals are an exemplary form of research activity. Research reported in annual reviews or in public information formats intended to inform the trauma system’s constituency can also be considered legitimate research activity. Optimal Elements I. The trauma MIS is used to facilitate ongoing assessment and assurance of system performance and outcomes and provides a basis for continuously improving the trauma system, including a cost-benefit analysis. (B-301) a. The lead agency has available for use the latest in computer/technology advances and analytic tools for monitoring injury prevention and control components of the trauma system. There is reporting on the outcome of implemented strategies for injury prevention and control programs within the trauma system. (I-301.4) II. The lead agency ensures that the trauma system demonstrates prevention and medical outreach activities within its defined service area. (B-306) a. The trauma system has developed mechanisms to engage the general medical community and other system participants in their research findings and performance improvement efforts. (I-306.1) b. The effect or impact of outreach programs (medical community training/support and prevention activities) is evaluated as part of a system performance improvement process. (I-306.3) III. To maintain its state, regional, or local designation, each hospital will continually work to improve the trauma care as measured by patient outcomes. (B-307) a. The trauma system implements and regularly reviews a standardized report on patient care outcomes as measured against national norms. (I307.2) Current Status Any efforts made by the trauma system to lead or support research in trauma are severely limited by inadequate levels of staffing, funding, and expertise. The trauma system does not currently track or facilitate trauma research. Furthermore, the absence of trauma system structure, policy and process, and data linkages hamper the conduct of important research within the trauma system. The absence of a trauma system plan prevents the identification of trauma system resources, system needs, gaps, and prioritized areas for research. Having no statewide trauma research agenda inhibits collaborative research efforts at the regional and local levels. This represents a lost opportunity for trauma system improvement as well as improved clinical care. The lack of specific policy or processes to request statewide data 78

from the trauma registry, insufficient expertise in research grant writing, and the lack of knowledge about ongoing trauma center research are additional impediments. Collaboration between the trauma system and various state agencies and resources may provide the lead agency with vital manpower and expertise to advance trauma research in South Carolina. These agencies include, but are not limited to, the South Carolina Data Oversight Council, the Office of Research and Statistics, the Office of Public Health Statistics and Information Services, and the Arnold School of Public Health (University of South Carolina). These resources may provide assistance with data access, data inquiry, grant writing, and multidisciplinary research projects. The state encourages trauma research at the Level I trauma centers by requiring this activity as criteria for center designation. Specifically, the criteria require active participation in trauma research and publication in professional journals (Chapter 19.1) and the administration of the trauma centers must demonstrate support of the research program (Chapter 19.6). These criteria are not consistent with research publication criteria of the ACS-COT Verification and Review program for Level I trauma centers. As a result, research efforts at individual trauma centers are diluted. Current research efforts at the local level revolve around inquiries at individual trauma centers. These efforts are not guided or informed by state trauma registry data or population-based data at the regional or state level, but rather focus on local issues. Trauma centers report that current lines of inquiry include the examination of obesity as an independent risk factor for increased morbidity and mortality in trauma, therapy in patients with cervical collars as it relates to aspiration prevention, effects of posttraumatic stress reactions in trauma patients, and antibiotic use for orthopedic injuries as a risk factor for hospital acquired pneumonia. Recommendations 

Develop a policy and procedure for state trauma registry data requests.

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Compile and maintain an updated list of trauma research conducted by South Carolina trauma centers.

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Develop a statewide trauma research agenda which focuses on priorities as established by the trauma system plan.

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Appendix A: Acronyms ACS-COT – American College of Surgeons Committee on Trauma ALS – advanced life support ATLS – Advanced Trauma Life Support ATCN – Advanced Trauma Care for Nurses BIS – Benchmarks, Indicators, and Scoring BLS – basic life support CARF – Commission on the Accreditation of Rehabilitation Facilities CDC – Centers for Disease Control and Prevention DHEC – Department of Health and Environmental Control DIVP – Division of Injury and Violence Prevention DUI – driving under the influence EMS – emergency medical services EMSC – Emergency Medical Services for Children EMT – emergency medical technician EOC – emergency operations center EOP – emergency operations plans FARS – Fatality Analysis Reporting System FTE – full-time equivalent FY – fiscal year GIS – geographic information systems HRSA – Health Resources and Services Administration ISS – injury severity score IT – information technology NREMT – National Registry for Emergency Medical Technicians NTDB – National Trauma Data Bank NTDS – National Trauma Data Standard PI – performance improvement PreMIS – prehospital management information system PSAPs – public safety answering points RTTDC – Rural Trauma Team Development Course SCI – spinal cord injury SMARTT – State Medical Asset Resource Tracking Tool 80

STEMI – ST elevation myocardial infarction TAC – Trauma Advisory Council TASC – Trauma Association of South Carolina TBI – traumatic brain injury TNCC – Trauma Nursing Core Curriculum TPM – trauma program manager TQIP – Trauma Quality Improvement Program TSC – trauma system consultation USC – University of South Carolina

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Appendix B: Methodology The South Carolina Department of Health and Environmental Control (DHEC) requested this trauma system consultation, which was conducted under the auspices of the American College of Surgeons (ACS) Trauma System Consultation (TSC) program. The multidisciplinary Trauma System Consultation (TSC) team consisted of: three trauma/general surgeons, one emergency physician, a state EMS/trauma director, a trauma program manager, a rural trauma and prehospital specialist, and a public health and injury specialist. Biographical sketches for team members are included as Appendix C of this report. The primary objective of this ACS trauma system consultation was to guide and help promote a sustainable effort in the graduated development of an inclusive and integrated system of trauma care for the State of South Carolina. The format of this report correlates with the public health framework of assessment, policy development, and assurance outlined in the ACS Regional Trauma Systems Optimal Elements, Integration, and Assessment: Systems Consultation Guide. Prior to the visit, the TSC team reviewed the ACS Pre-Review Questionnaire (PRQ) submitted by the DHEC, along with a number of related supporting documents provided by the DHEC and information available on government websites. The TSC team convened in Columbia, South Carolina on May 19-22-, 2014, to review the South Carolina trauma system. The meetings during the four-day visit consisted of plenary sessions during which the TSC team engaged in interactive dialogue with a broad range of representative trauma system participants. There was also an opportunity for informal discussion with the participants and time devoted to questions and answers. During the survey, the TSC team also met in sequestered sessions for more detailed reviews and discussion, and for the purpose of developing team consensus on the various issues, preparing a report of their findings, and developing recommendations for future development of the trauma system in South Carolina. This report was developed independently of any other trauma system consultations or assessments.

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Appendix C: Review Team Biographical Sketches ROBERT J. WINCHELL, MD, FACS- TEAM LEADER

Dr. Robert Winchell is currently head of the Division of Trauma and Burn Surgery at the Maine Medical Center and Associate Professor of Surgery at the Tufts University School of Medicine. He received his undergraduate degree from the California Institute of Technology, his M.D. from Yale University, and did his internship, General Surgery residency, and Trauma and Critical Care Fellowship at the University of California, San Diego, where he remained on the faculty as Associate Professor of Clinical Surgery in the Division of Trauma through 1999. After leaving the University of California, Dr. Winchell established and subsequently directed the Tacoma Trauma Center in Tacoma, Washington. The trauma center continues to operate successfully as a joint venture between two previously competing hospitals. In 2001, Dr. Winchell moved to the Maine Medical Center and assumed his current post in 2004. Dr. Winchell has been involved in trauma center and trauma system design and operation in a wide variety of settings covering the spectrum of system development. He was instrumentally involved with both the day-to-day operations and ongoing development of the San Diego County trauma system for over ten years and served as chair of the San Diego and Imperial County Committee on Trauma. He participated in the operation and ongoing development of the Washington state trauma system, serving on the state advisory board, and as chair of the Southwest EMS region. Since moving to Maine, Dr. Winchell has worked to develop the Maine state system, is a member of the state advisory board, and is a past chairman of the Maine State Committee on Trauma. He is Chair of the Trauma Systems Evaluation and Planning Committee of the American College of Surgeons and also serves as a senior site reviewer for the trauma center verification program of the College. Dr. Winchell is Board certified in General Surgery, with added qualifications in Surgical Critical Care. Dr. Winchell is a Fellow of the American College of Surgeons as well as a member of the American Association for the Surgery of Trauma, the Association for Academic Surgery, the Southwest Surgical Congress, and the Society of Critical Care Medicine. He is author of more than 50 scientific papers and book chapters, and has given over 100 regional, national, and international presentations. JANE W. BALL, RN, DRPH

Dr. Jane W. Ball has served as a consultant to the Trauma Systems Evaluation and Planning Committee of the American College of Surgeons Committee on Trauma since 2006. As such, she has participated on more than 20 state and regional trauma system consultations. She was the Director of the National Resource Center (NRC) at the Children’s National Medical Center in Washington, D.C. from 1991 through 2006. The NRC provided support to two Federal Programs in the U. S. Department of Health and Human Services’ Health Services and Resources Administration (HRSA): the Emergency Medical Services for Children (EMSC) Program and the Trauma-Emergency Medical Services Systems Program. As director of the NRC, she participated in the development of the HRSA Model Trauma Systems Evaluation and Planning document. She also provided technical assistance to states regarding strategic planning, providing guidance in securing funding, developing and implementing grants, developing injury prevention plans and programs, building coalitions, shaping public policy, conducting training, and producing educational resource materials.

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Dr. Ball has authored numerous articles and publications as well as several health care textbooks, including Mosby’s Guide to Physical Examination (8 editions), Child Health Nursing (3 editions), Pediatric Nursing: Caring for Children (5 editions), Maternal and Child Nursing Care (4 editions), and Pediatric Emergencies: A Manual for Prehospital Care Providers (2 editions). One of these texts, Pediatric Nursing: Caring for Children, received the1999 and 2001 Robert Wood Johnson Foundation Last Acts Coalition Outstanding Specialty Book Award. Child Health Nursing was recognized as an American Journal of Nursing Book of the Year in 2010. As an expert in the emergency care of children, Dr. Ball has frequently been invited to join committees and professional groups that address the unique needs of children. Dr. Ball served as the President of the National Academies of Practice, an organization composed of distinguished health care practitioners from 10 disciplines that promote education, research, and public policy related to improving the quality of health care for all through interdisciplinary care. Dr. Ball graduated from the Johns Hopkins Hospital School of Nursing. She obtained her master’s degree and doctorate in Public Health from John Hopkins University School of Hygiene and Public Health. She is a Certified Pediatric Nurse Practitioner. She received the Distinguished Alumni Award from the Johns Hopkins University in 2010. MARIA FERNANDA JIMENEZ, MD, FACS

Dr. Maria Fernanda Jimenez is currently a professor of general surgery at the Universidad del Rosario in Bogota, Colombia, and she practices at the Hospital Universitario Mayor (MEDERI), which is a 1,000 bed level I facility. She completed her medical and general surgery training at Pontificia Universidad Javeriana in Bogoto, Colombia. This was followed by an 18 month adult critical care research fellowship at the University of Toronto, Canada with an emphasis on hemorrhagic shock and PMNs apoptosis. She previously served as the director of the emergency department and as general surgeon at Hospital Universitario San Ignacio in Bogota and as the adjunct director of the emergency department and general surgeon at la Fundacion Santa Fe de Bogota. Dr. Fernanda Jimenez is currently the president of the Asociacion Colombiana de Trauma, and previously served as this organization’s executive secretary. Dr. Fernanda Jimenez is currently the Chief of the American College of Surgeons Committee on Trauma Region 14, and she is actively engaged in having Committee on Trauma education programs taught in Latin America and the Caribbean. She previously served as the chairperson of the Colombia Chapter of the American College of Surgeons Committee on Trauma from 2009 to 2013. She is a member of the Board of Directors for the Panamerican Trauma Society. In addition to these organizations, she is an active member of the American Association for the Surgery of Trauma and Asociacion Colombiana de Cirugia. Her goals as president of the Asociacion Colombiana de Trauma and as Chief of the American College of Surgeons Committee on Trauma Region 14 are to improve the quality of care for trauma patients in Colombia, Latin American, and the Caribbean and to create a trauma system plan for Bogota. STEPHEN FLAHERTY, MD, FACS

Dr. Stephen Flaherty is a trauma surgeon at Mission Hospital in Asheville, NC. He graduated from the Tufts University School of Medicine and completed his general surgery residency at

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Eisenhower Army Medical Center in Augusta, GA. After working for a year as a general surgeon he returned to training as a fellow in trauma and surgical critical care at Boston City Hospital. He is board certified with added qualifications in Surgical Critical Care. Dr. Flaherty served on active duty with the United States Army for 22 years during which he established a Level I trauma center in San Antonio, TX and a Level II trauma center in Landstuhl, Germany, the first ACS Verified trauma center outside the United States. His Army experience brought him a broad experience across all levels of the trauma system including oversight of the trauma system in Iraq and Afghanistan as the Director the Joint Theater Trauma System for nine months. Dr. Flaherty is a member of the American College of Surgeons Committee on Trauma where he participates on the Trauma Systems Evaluation and Planning Committee as well as the Performance Improvement and Patient Safety Committee. He is a member of the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, the Society of Critical Care Medicine, and the American College of Surgeons. He has numerous publications and presentations on topics in trauma and critical care. HEIDI HOTZ, RN

Heidi Hotz is the Trauma Program Manager at Cedars-Sinai Medical Center, a Department of Health designated and ACS verified Level I Trauma Center. She is also the President of the Los Angeles Association of Trauma Program Managers as well as the Immediate Past President of the American Trauma Society (ATS), Past President of the Society of Trauma Nurses (STN), and Past President of the Trauma Managers Association of California (TMAC). She has extensive experience in all aspects of trauma including clinical care, program management, trauma data, trauma performance improvement and patient safety, trauma systems, injury prevention, consultation for trauma centers and systems, educational curriculum development, conference and event planning and all trauma related issues across the continuum of care. She is the recipient of the STN’s Trauma Leadership Award. She has been a survey team member for the ACS Trauma Systems and Evaluation Program. She has been an invited expert panel member for many national trauma initiatives and projects such as the ATS Leadership Forums, the screening & brief intervention for alcohol in trauma initiatives, the Model Trauma System Plan work group, to name a few. She has lectured on a wide variety of trauma related topics throughout the United States and internationally. She has extensive participation at the member and Chair levels for local, regional, state and national committees. She was the Chair of the Advanced Trauma Care for Nurses® (ATCN) Committee in Arizona for 6 years. She was then appointed the first Chair of the STN’s ATCN National-International Committee and spearheaded the special projects team to attain the ACS COT approval of the program as a collaborative effort with the ATLS Subcommittee. She was a member of the STN Board of Directors for over 8 years in the positions of Director at Large, Treasurer, President Elect and President. She is an author and Faculty Member for the STN’s Trauma Outcomes Performance Improvement Course (TOPIC). FERGUS LAUGHRIDGE, AEMT, CPM

Fergus Laughridge has a diverse professional background as a police officer, firefighter, paramedic, and manager of EMS systems and operations. Mr. Laughridge has served as the Director of Nevada State Health Division, Emergency Medical Systems and Trauma program where he was responsible for assuring the quality of pre-hospital emergency medical and

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trauma services throughout Nevada. As State EMS Director, he was involved with numerous federal, state, and community activities relating to emergency preparedness and response. Mr. Laughridge is currently employed by Humboldt General Hospital EMS and Rescue in Winnemucca, Nevada. Mr. Laughridge has recently assumed the responsibilities of managing a new division that specializes in providing diverse medical services to mining and industrial operations across Nevada. Mr. Laughridge is continually requested to serve on various committees centered on quality patient care, trauma systems, and credentialing of EMS systems. HOLLY MICHAELS

Holly Michaels has served as the American College of Surgeons (ACS) Trauma Systems Consultation Program Administrator since 2007. In this role, Ms. Michaels has facilitated over 20 state and regional consultations and managed several Trauma System Evaluation and Planning Committee projects related to trauma systems development and evaluation. Ms. Michaels graduated from the University of South Florida in 2001, with a Bachelor of Arts degree in English. She began her career in public health as a health education coordinator at 21-1 Tampa Bay Cares, a non-profit organization in Clearwater, Florida connecting the community with health and social service resources. Ms. Michaels is a graduate student at the University of Illinois at Chicago in the Masters of Public Health program, with a focus in community health. KATHY J. RINNERT, MD, MPH, FACEP

Kathy J. Rinnert, MD, M.P.H., FACEP, began her career in emergency medicine and emergency medical services (EMS) in the early 1980's as a Nationally Registered Paramedic in a five-county, rural EMS agency in the Allegheny Mountains of Southeast Ohio. She completed medical school at the Ohio State University, followed by an internship in Internal Medicine at Loyola University, and residency training in Emergency Medicine at the University of Chicago. Following residency, Dr. Rinnert completed a two-year fellowship in Emergency Medical Services (EMS) at the University of Pittsburgh. She simultaneously obtained a Master’s in Public Health at the Graduate School during her tenure in Pittsburgh. Dr. Rinnert is currently a Professor of Emergency Medicine at the University of Texas Southwestern Medical Center at Dallas (UTSWMC). She is the Associate Medical Director for the UTSW/BioTel EMS system, encompassing sixteen municipalities and their fire-based EMS and Public Safety agencies. In this capacity, she oversees the out-of-hospital practice of over 1700 paramedics operating in urban, suburban, and rural environments. Dr. Rinnert directs the Center for Government Emergency Medical Security Services (GEMSS) at the UTSWMC, which provides academic and clinical tactical support to government agencies. At the Center, she directs both the EMS and GEMSS fellowship programs, which provide post-doctoral training in these subspecialty areas of emergency medicine. Dr. Rinnert has special interest and expertise in trauma, injury prevention and control, air medical transport, tactical EMS, urban search and rescue, and domestic preparedness for weapons of mass effect (WME) and counterterrorism. She is a member of the Board of Directors for the Commission on Accreditation of Ambulance Services (CAAS), the national body for accreditation of EMS agencies in the United States and Canada. Dr. Rinnert is an

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active grant reviewer for the Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health (CDC-NIOSH) and trauma systems consultant to the American College of Surgeons Committee on Trauma (ACS-COT). NELS D. SANDDAL, PHD, MS, REMT-B

Dr. Sanddal is currently the Manager of the American College of Surgeons (ACS) Trauma Systems and Verification Programs. Prior to his current position, he served as President of the Critical Illness and Trauma Foundation (CIT), in Bozeman, Montana for 25 years. He worked as the training coordinator for the EMS and Injury Prevention Section of the Montana Department of Public Health and Human Services in the late 1970’s. He has served as the Chairperson of the National Council of State EMS Training Coordinators and as the lead staff member for that organization, and similarly for the National Association of EMT. Dr. Sanddal completed his undergraduate work at Carroll College, received his Master’s degree in psychology from Montana State University and his doctorate in Health Science from Walden University. He has been a co-investigator for six state or regional rural preventable trauma mortality studies and has conducted research in the areas of training for medical personnel, suicide, and rural injury prevention and control. Nels served on the Institute of Medicine’s Committee on the Future of Emergency Care in the U.S. Healthcare System. He received his EMT training in Boulder, Montana, in 1973 and has been an active EMT with numerous volunteer ambulance services since that time and has managed three EMS agencies. When he is at his home in Montana, Nels responds with the Gallatin River Ranch Volunteer Fire Department where he serves as the Chief Medical Officer and Assistant Fire Chief.

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Appendix D: Participant List Name Adam Rudd Alison Burns Alonzo Smith Amy Hamrick Angie Vickery Arnold Alier Arthur Cooler Benjamin Manning Betsy Barton Brent Raley Brian Fletcher Carol Ann Dean Chuck Marrow Crystal Youmans Dana Burke David Cothran Debbie Coulliard Debra Kitchens Diane Howell Don Whiteley Doug Norcross Ed DesChamps Era Zeigler Gil Rimleus Greg Squires Jay Blankenship Jay Hamm Jeff Carroll Jessica Schmittle Jill Cleary Jim Foster Jimmy Greene Jimmy Walker Juan Camps Julie McCabe Julie Murray

Organization Hospital Corporation of America Grandstrand Medical Center Richland County Spartanburg Regional Medical Center Self Regional Medical Center Department of Health and Environmental Control Carolina Pines Regional Medical Center Greenville Health Systems Department of Health and Environmental Control Lexington Medical Center Medical University of South Carolina Palmetto Health Richland Spartanburg Regional Medical Center Calhoun County EMS Palmetto Health Richland AnMed Health Medical University of South Carolina Medical Center of Central Georgia McLeod Regional Department of Health and Environmental Control Medical University of South Carolina Department of Health and Environmental Control Trident Medical Center Conway Medical Center Trident Medical Center Spartanburg EMS Palmetto Health Richland Spartanburg EMS Department of Health and Environmental Control East Cooper Medical Center AnMed Health Spartanburg Regional Medical Center South Carolina Hospital Association Palmetto Health Children's Hospital Department of Health and Environmental Control Palmetto Health Richland

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Karen Moore Karl Leistikow Khosrow Heidari Lewis Dicksinson Lori McEwan Lynn Foster Lynn Newsom Mandy Felder Melinda Merrell Michele Walk Mike Fair Nichole Spivey Owens Goff Paul Cooper Paul Hubbard Randy Langston Raymond Bynoe Regina Creech Richard Naugler Rich Wisniewski Robert Gates Robert Wronski Sarah Mathis Sherry Hankins Stefanie Corbette Stephen Fann Steve Lanning Tara Divido Theresa Lynn Tiffin Lamoreaux Tony Minshew Walter Blessing

Department of Health and Environmental Control Trident Medical Center Department of Health and Environmental Control Grandstrand Medical Center Carolinas Hospital McLeod Regional Carolina Pines Regional Medical Center Lab Corp South Carolina Office of Rural Health Piedmont Medical Center South Carolina Senate Palmetto Health Department of Health and Environmental Control EMS Performance Improvement Center AnMed Health Department of Health and Environmental Control Palmetto Health Richland Medical University of South Carolina Department of Health and Environmental Control Department of Health and Environmental Control Greenville Health Systems Department of Health and Environmental Control SC Office of Rural Health Roper St. Francis Department of Health and Environmental Control Medical University of South Carolina Conway Medical Center AnMed Health East Cooper Medical Center Roper St. Francis Conway Medical Center Roper St. Francis

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Appendix E: Trauma Registrar Sample Job Description The Trauma Registrar should optimally hold a bachelor’s degree in a behavioral, social, or health science or health-related field with emphasis in statistics or biostatistics and research methods. This position requires a minimum of two years’ experience in research methods/statistical analysis and application, and conducting health or health care delivery research. A master’s degree will substitute two years practical experience. Responsibilities might include, but are not limited to: 

Validate data that is submitted to the Division of Health o Develop and implement a system or methodology to statistically validate data that is submitted for every ambulance run and every major trauma patient admission to Navajo Nation hospitals. o Provide feedback to ambulance and hospital personnel on appropriate submission of data. o Maintain the trauma registry database o Respond to requests by management for special studies and data analysis.

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Provide educational support for end users of the trauma registry database. o Provide quarterly, regional training in data submission and quality assurance to ambulance services and hospitals. o Develop and continually refine a best practices guide for data submission and use for ambulance services and hospitals. o Make presentations at state and regional conferences to explain best practices for data submission and use. o Assist EMS agencies with benchmarking EMS performance measures. These benchmarks can drive local allocation of EMS resources to better serve the public.

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Production of statistical reports o Research, analyze, and draft monthly and annual reports. o Design report formats and content. o Final report editing and preparation before printing and distributing reports. o Make presentations to departmental, state, and regional groups describing data driven conclusions about emergency health care within the Navajo Nation. o Provide ad hoc statistical reports to Division of Health staff upon request. o Work with external customer’s requests for data.

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Act as a liaison between the Division of Health, contracted software vendors, and national and state data repositories. o Work with software vendors to resolve any technical issues identified with the trauma registry database. 90

o Ensure the data dictionary of the trauma registry is compliant with the National Trauma Data Bank project. o Submit validated raw data to national data repositories while remaining in compliance with privacy laws and regulations. o Work with the Arizona and New Mexico Departments of Health on trauma registry data sharing.

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Appendix F: Sample List of Statewide PI Indicators Quality Improvement/PERFORMANCE IMPROVEMENT The mission of the performance improvement (PI) process is to continuously improve trauma care outcomes. These programs analyze trends and patterns, utilizing data provided from the trauma registry and from the regional providers of trauma care services. Suggestions for PI Indicators Prehospital:  Missing initial patient care report in chart  Scene time > 20 minutes  Lack of appropriate spinal stabilization, including overuse  Unmanaged airway on arrival at hospital  Uncontrolled external bleeding on arrival at hospital  Appropriateness of triage - missed trauma team activation – patient met criteria, but trauma team activation was not called from the field by EMS  Lack of warming procedures (hypothermia) Hospital:  Trauma Deaths (Include if the death regardless of whether it did or did not include opportunities for improvement)  Transfers after two hours from arrival  GCS < 8 and airway not established  Missed trauma team activations on patients meeting activation criteria  Did not confirm ET tube placement  Inappropriate spinal stabilization, including unnecessary delays in spinal clearance  Trauma team member response beyond specified time allowed  Inappropriately or non-splinted fractures  Transport or treatment delays caused by CT scans  Lack of utilizing core warming interventions (hypothermia)

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