South Central Kansas Trauma Region General Membership Meeting Wesley Medical Center

South Central Kansas Trauma Region
General Membership Meeting
Wesley Medical Center
Cessna Conference Room
Wichita
April 26, 2011
10:00am – 3:00pm
Call to Order and Welcome
Dr. Tyson Blatchford, chairman, called the 2011 SCKTR General Membership Meeting to order. Dr.
Blatchford “thanked” Wesley Medical Center for hosting the meeting. He asked all members to
introduce themselves and the organization that they represent. Dr. Blatchford reminded the members
to complete their evaluations throughout the day, sign the sign-in roster, and complete their statement
of attendance for continuing education credits.
Trauma System Development
Rosanne Rutkowski, Kansas Trauma Program Director, provided the presentation. Her presentation
provided information on the program’s achievements, current projects, and future goals. Click here to
view her presentation.
Interpreting Trauma Registry Data
Dee Vernberg, Trauma Program Epidemiologist, provided findings from trauma registry data for the
SC region. Her presentation described characteristics of the SC Trauma Region and outlined the two
primary ways trauma registry can be used to enhance system development (primary prevention and
performance improvement
Implementing an Injury Prevention Program in Your Community
Dr. Amy Chesser, KU School of Medicine, provided the presentation. Click here to view her
presentation.
Lunch-Injury Prevention Vendor Display
PHTLS in Kansas
Bill Auchterlonie, Hutchinson Community College and PHTLS Affiliate Faculty, provided the
presentation. Click here to view his presentation.
Case Study Presentations
Two case study presentations were highlighted. The first case highlighted was a patient that received
care at Lyons County Hospital, Promise Regional Medical Center, and Wesley Medical Center. This
case was presented by Dr. Stacy Dashiell, Michelle Schrag (on behalf of Dr. John Shaw), and Dr.
Dave Acuna. Click here to view presentation.
The second case highlighted a patient that received care at Via Christi Hospital. This case was
presented by Dr. James Haan. Click here to view presentation.
Community Health Assessment: The Things Your Hospital Needs to Know About the Process
Sara Roberts, Kansas Rural Health Program Director, presented the presentation. Click here to view
presentation.
1
Business Meeting
Nominating Committee
Kris Hill, Nomination Committee Chair, introduced the executive committee nominees. Kris asked for
nominations from the floor for each discipline. After nominations were made, Kris asked the
nominees to give a brief description about themselves and why they would like to serve on the
executive committee.
 Nominations
o Hospital Administrator
 Nancy Zimmerman, Comanche County Hospital
o EMS
 Anderson Lowe, Halstead EMS
 Rita Gumm, Via Christi Transport
 Grant Helferich, Butler County EMS
 Scott Fleming, Comanche County EMS
o Health Department
 Jo Miller, Harvey County Health Department
o Nurse
 Kris Hill, Via Christi Hospital
 Diana Lippoldt, Wesley Medical Center
 Shelley Pinnegar, South Central Kansas Medical Center
o Physician
 Tyson Blatchford, MD-South Central Kansas Regional
Medical Center
 James Haan, MD, FACS, Via Christi Hospital.
Dr. Blatchford asked the voting members to complete their voting ballot.
 Education Subcommittee
Diana Lippoldt provided the following report:
In the past year, the following classes have been funded through the regional trauma council:
PHTLS
 Marion County EMS
o April 24 & 25, 2010
o 13 participants

Kiowa County EMS
o Holding course this spring
TNCC
 South Central Kansas Regional Medical Center
o May 5 & 6, 2010
o 14 participants
 Newton Medical Center
o November 29 & 30, 2010
o 14 participants
2


Promise Regional Medical Center
o October 25 & 26, 2010
o 13 participants
Pratt Regional Medical Center
o November 30 & December 1, 2010
o 17 participants
RTTDC
o Sumner Regional Medical Center
o October 6, 2010
o 25 participants
o Sumner Regional Medical Center
o September 22, 2010
o 15 participants
o Hillsboro Community Hospital
o September 16, 2010
o 19 participants
Goals/notes from February 2011 executive committee meeting
 Continue to support PHTLS, TNCC, RTTDC, ATLS
 Prehospital-questions were raised regarding education for prehospital providers. What
classes are being taught, what resources are available
 DMEP (ACS sponsored class)-Diana advised that this class was recently held in the SC
region and well attended. This class is lead by trauma surgeons/physicians. She would
like to research the opportunity of offering the class again in the region. Diana also
advised that she would like to research the possibility of hosting a train- the –trainer
class. She suggested partnering with the emergency & hospital preparedness region to
help support the program
 Performance Improvement (PI) Conference-The subcommittee would like to host a PI
workshop similar to the NE workshop held in October 2010. The tentative date for the
workshop is November 3rd, the day before the Statewide Meeting of the Executive
Committees.
Trauma Program website. We encourage organizations as they schedule trauma education that is
open to outside organizations, please contact Jeanette and we will place the classes on the trauma
education calendar. The trauma website is www.kstrauma.org.
 Injury Prevention Subcommittee
Ronda Lusk & Teena Johnston, Committee Co-Chairs, provided the following reports:
Fall Prevention
Ronda has purchased the updated NFPA fall and burn curriculum. The plan is to host a trainthe-trainer workshop inviting all of the regional health departments. We will possibly be
working with the SC regional health department committee to provide the education.
Teen Driving Awareness
Battle of the Buckles program is underway in the region.
3
Bylaws (action)
The proposed bylaws included the addition of ACT language. After review of the bylaws, Chad
Pore made the motion to approve the bylaws as presented. Nancy Zimmerman seconded the
motion. The motion passed.
Regional Trauma Plan (action)
The SC regional trauma plan has been updated and edited. The regional trauma plan format
reflects a work plan format. The regional budget has also been edited to mirror the regional
trauma plan and will be used to accomplish goals and objectives of the plan. After review, Dr.
William Waswick made the motion to approve the regional trauma plan as presented. Chad Pore
seconded the motion. The motion passed.
Election of executive Committee Members (Action)
Dr. Blatchford announced the executive committee election results:
 Health Department Representative: Jo Miller, Harvey County Health
Department
 EMS Representative: Grant Helferich, Butler County EMS
 Administrator Representative: Nancy Zimmerman, Comanche County
Hospital
 Nurse Representative: Kris Hill, Via Christi Hospital
 Physician Representative: Dr. James Haan, Via Christi Hospital
In Closing
Dr. Blatchford “thanked” Wesley Medical Center staff for hosting the meeting and “thanked”
everyone for attending.
Adjournment
Meeting adjourned at 3:15pm.
4
Kansas Trauma System Update
2011
Rosanne Rutkowski, RN, MPH
Kansas Trauma Program
Welcome
• Objectives:
– What's been accomplished in 2010
• State
• Regional
– Projects 2011
• Level IV Designation
• Regional performance improvement
Our Journey Continues…..
Why develop a trauma system?
• Trauma Systems Save Lives
– San Diego: decreased preventable deaths
from 14% to 3%
• J Trauma 1986 Sept: 26 (9): 812-20
– Oregon: 18% reduction in mortality
• J Trauma 1998: 44(4): 609-16
– Florida: 15% reduction in mortality
• J Trauma 2006: 60 (2): 371-78
Kansas Trauma System “Roadmap”
Progress to Date
2010 Accomplishments
•
•
•
•
•
Policy Committee-Updated the benchmark report
Level IV trauma center criteria developed
Developed electronic linkage w/ EMS data
Fall & Regional Trauma Council Meetings
Grants Awarded:
–
–
–
–
CDC Field Triage Project
Christopher Reeves Foundation
NHTSA Data Linkage w/ KBEMS
Flex funding
• Peer Review Article on Kansas System
Work in Progress 2011
• Public Information
– Updating the trauma DVD
• CDC Field Triage Project
– Pilot Project in SE trauma region
• Legislation
– Peer Review Protections- SB 139
• Regulations
– Level IV
CDC Field Triage Project
• Kansas one of three states awarded funding
– EMS presence on National Expert Panel
• Pilot test the CDC Field Triage guidelines in
one trauma region
• Evaluate at the end of 6 months/ April 2011
• Promote implementation of guidelines
statewide
Level IV Trauma Center Criteria
– In approval process
– Criteria developed- handout
– Application form developed-needs formal approval
– Next Steps
• to be approved at May ACT
• Regulations to Secretary of Administration
PROCEDURE FOR APPROVAL OF REGULATIONS
Agency
Rule or Regulation
Secretary of Administration
Attorney General
Kansas Register
Joint Committee on Rules and Regulations
Open Hearing
Agency Approval
Secretary of State
Kansas Register
15 days after publication
Trauma System Performance
Improvement
• Problem:
• Current trauma statutes do not provide
protections for review of trauma cases
• Solution:
• Update current trauma statutes
• Provide Peer Review Protections
– Advisory Committee on Trauma
– Regional Trauma Councils
• SB- 139
Bill History SB 139
• Feb. 8 Introduced Senate & Referred to
Senate Public Health & Welfare
• Feb 15 Hearing Held, Testimony Provided
• Feb 23 Passed Senate Yes: 28 Nay: 11
• Feb 25 House Health & Human Services
• Mar. 9 Hearing Held, Testimony Provided
• Currently in Health Conference Committee
How laws are written
As Committee
Reported It
As House Amended It
As Senate Amended It
As the bill was
introduced
What the Budget
Allowed
As Passed Into Law
As Agency Understood It
What The Taxpayer
Wanted
How Media Reported It
Important Legislative Information:
• Two Important things to know:
– Toll free number: 1-800-432-3924
– Web site: www.kslegislature.org
Performance Improvement…
• is the process of continually reviewing,
assessing and refining practices to
improve patient outcomes.
– Collect high quality data
– Review information it in proven multidisciplinary processes
– Identifying strategies to implement needed
changes
– Communicating to all stakeholders
What are the Qualities of a Good
Trauma System?
• Network of hospitals with the
commitment and the resources to care
for trauma system patients
• Organized plan to route critical patients
to the right hospital that is ready to care
for them
• Constant monitoring of the system to
correct problems, improve the system,
and validate the quality of care
provided
How does the System Save Lives?
• It correctly identifies the patients who need
trauma care
• Anticipates the resources needed to treat the
patients
• Locates the available needed resources
• Routes the patient “right” the first time to
reduce time to appropriate care
• Arranges interfacility transfers if needed to
reduce time to appropriate care
• Improves care by the PI process
How to Make a Difference
• Participate with your regional trauma
council
• Education of EMS, RN’s, MD’s &
Registrars
• Contact your legislator
• Encourage participation
• Spread the news & Share the wealth!
“Being a trauma center is a journey, not
a destination. But…
It’s a journey our patients will be grateful that
we made”.
Trauma Director
Questions??
Thank you!
Implementing an
Injury Prevention Program
in Your Community
Amy Chesser, PhD
Research Assistant Professor
University of Kansas School of Medicine - Wichita
Agenda

Introduction

Developing a program
◦ What matters
◦ Where to begin

Injury Prevention Resources

Questions
Amy Chesser, PhD
INTRODUCTION
Social
Marketing
Social Media
Health
Education
and
Promotion
Health
Communication
Communication
Campaigns
Physician Patient
Communication
How People Seek Health
Information
Now thinking about all the sources you turn to when you need
information or assistance in dealing with health or medical issues,
please tell me if you use any of the following sources…
– 86% of all adults ask a health professional, such as a doctor
– 68% of all adults ask a friend or family member
– 57% of all adults use the internet
Also, 81% of internet users say they go online and do something
related to health less often than once a week.
Source: Susannah Fox and Sydney Jones (2009). The social life of information. Pew Internet & American Life Project.
5
Injury Prevention
Mass Communication
Organizational
Small Group
YOU
Interpersonal
Intrapersonal
Starter Kit
DEVELOPING
INJURY PREVENTION
PROGRAMS
Injury Prevention
Bike Helmets/Safety
 Fire Arms
 Drowning Prevention
 Falls in the Elderly
 Pedestrian Safety
 SIDS

Getting Started
Evidence-based Decisions
 Community Partners
 Building a program

◦ Resources
◦ What have others done?
◦ The Competition
Evaluation
 What will it cost to do NOTHING?

IP: Building a Program

Step 1: Choose a topic
◦ Drowning Prevention

Step 2: Find some other passionate
people
◦ SafeKids: Local, State and National

Step 3: Get together
◦ Assess resources
◦ Find out what others are currently doing
◦ Discuss timing (competing initiatives)
10
IP: Building a Program

Build a core message
No one should die of
unintentional drowning
IP: Building a Program
◦ If you can, include a research geek…
 Previous work
 Formative research
 Publications
 Organizations producing like work
12
The Competition
We must hear a
message 7 times to
remember what was
communicated
The average American
receives more than
3,000 advertising
messages every day
13
The Other Competition

Community Initiatives

State Programs
◦ Timing
◦ Funds
◦ Human Resources
14
Additional Support
INJURY PREVENTION
RESOURCES
The Community Toolbox

http://ctb.ku.edu/en/default.aspx
WISQUARS Data
http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html
17
APHA

http://action.apha.org/site/MessageViewer?dlv_id=18141&em_id=13782.0

http://action.apha.org/site/MessageViewer?dlv_id=18163&em_id=13784.0

http://action.apha.org/site/MessageViewer?dlv_id=18201&em_id=13785.0
CDC Resources

http://www.cdc.gov/ncipc/injweb/websites.htm
Pre-Hospital Trauma
Life Support
(PHTLS)
th
7
Edition
Over 25 Years of Trauma Training
PHTLS Committee
• Will Chapleau – Chairman
• Dr. Norman McSwain – Medical Director
• Dr. Jeffery Guy – Associate Medical Director
PHTLS Committee
•
•
•
•
•
•
•
•
•
•
•
Will Chapleau – Chairman
Dr. Norman McSwain – Medical Director
Dr. Jeffery Guy – Associate Medical Director
Dr. Peter Pons – Associate Medical Director
Dr. Lance Stuke – Associate Medical Director
Greg Chapman – Vice Chairman
Dennis Rowe
Mike Hunter - Eastern Region Coordinator
Augie Bamonti - Central Region Coordinator
Craig Jacobus - Western Region Coordinator
Mark Lueder - TCCC Liaison
PHTLS Office Staff
• Corine Curd
Education Manager
• Trevor Hicks
Education Outreach
• Sylvia McGowan
Education Coordinator
The PHTLS Committee would like to
thank…
• Dr. Jeffrey Salomone
– Editor of 6th and 7th editions of PHTLS
– Past EC member
Strategic Partnerships
• American College of Surgeons
– Committee on Trauma
• Society of Trauma Nurses
• Committee of Tactical Combat Casualty Care
Over 25 years of Trauma
Education
• Over 600,000 providers trained in over 45
countries
• 6th edition was translated into 11 languages
PHTLS in Kansas
•
•
•
•
Combined Providers …… 1369
Advanced Providers …… 668
Basic Providers
…… 60
Military Providers …… 29
• Advanced Refreshers ….. 41
PHTLS Instructors in Kansas
• PHTLS Instructors …. 124
• Military Instructors …. 2
Faculty
• Instructors active …. 64
• Affiliate faculty
…. 7
• Course coordinators … 100
• State Coordinator
…. 1
• Regional Coordinator … 1
This Revision
• Most extensive revision in the history of
PHTLS
• New texts
• New programs
• Each of our international partnership
countries contributed to this edition
PHTLS 7/E
Release Date: 11/17/10
Military PHTLS 7/E
Release Date: 11/17/10
New Program
TRAUMA FIRST RESPONSE
Available: MARCH 2011
Requesting Desk Copies
• Complete a Desk Copy Request Form with
program information and SHIPPING address
– UPS will not ship to a P.O. Box
• Contact your state EMS Specialist from
Elsevier
EMS Specialist – West/Midwest
Barb Schneider 800-325-7680 x3
[email protected]
Alaska
Arizona
California
Colorado
Hawaii
Idaho
Kansas
Minnesota
Montana
Nebraska
Nevada
New Mexico
North Dakota
Oregon
South Dakota
Utah
Washington
Wyoming
PHTLS WEB SITE:
WHAT’S ON THE HORIZON
Online Education
Purchase Books
Find a Course
State and Regional Coordinators will
Continue to receive notification of up-coming
Courses, and missing student rosters.
ADDITIONAL MATERIAL
Articles, case studies or new information will
be posted on the website after Executive
Council review.
Navigation to reach new material will be
streamlined for Provider use.
PHTLS
th
7
EDITION
Textbook Changes
7th Edition – General Philosophy
• Incorporate changes from the 8th edition Advanced
Trauma Life Support® course of the Committee on
Trauma of the American College of Surgeons.
– Increased emphasis on evidence published in the medical
literature
• Continue to be “evidence-based” to the extent
possible, demonstrating the science behind PHTLS
– Incorporate data from new clinical research on trauma
care in the prehospital setting
– Incorporate position papers as appropriate from national
EMS organizations, such as the National Association of
EMS Physicians
7th Edition – General Philosophy
• Ensure the course focuses on “principles” not
“preferences” (protocols) to provide
prehospital care providers with the knowledge
base to make reasonable patient care
decisions
– No “official PHTLS way” to perform skills
– Principle for each skill stated
– Illustration of one acceptable method of
performing the skill that meets the principle
• Book organized into logical sections
7th Edition – Major Sections
• Division I – Introduction
• Division II – Assessment and Management
• Division III – Specific Injuries
• Division IV – Summary
• Division V – Mass Casualties and Terrorism
• Division VI – Special Considerations
PHTLS
th
7
Edition
Provider Programs
Overview
Provider Program
• Based on 16 contact hours
– Can be delivered in multiple schedules based on
needs
• Focuses on the “Principles” of trauma care
versus personal or local service “Preference”
– Example: Procedure required not specific device
• Utilizes the A-B-C-D-E approach to patient
assessment and care
Interactive Scenarios
Overview and Instructions
– Critical Action
– Equipment list
– Time management of station
 5 minutes: Overview of station, expectations, review of
equipment
 25 minutes: scenario management
 10 minutes: review and discussion
 5 minutes: travel to next station
Scenario Template
• Same template utilized for baseline,
interactive, & finial evaluation stations
• Numbering system: D-4-C-A
– A, B, C, D, M
– Sequential number
– Critical or non-critical
– Adult or pediatric
Scenario
• Faculty Information
– Summary, goals
– Patient moulage & instructions
• Italicized text is read to each group of
participants
• Station information/expectations
• Selection of team leader
• Dispatch information
Evaluation Form
Divided into:
• 6 sections
– Scene size-up, primary survey, secondary survey,
reassessment, transportation, communication
• 4 columns
– Instructor Information, findings, participant
actions, instructor notes
• End of scenario questions/discussion points
PHTLS
th
7
Edition
Refresher Program
Overview
Refresher Program
SAMPLE COURSE PLAN
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Welcome and Introductions
Overview of Trauma Care
A&B Airway and Breathing
C&D Circulation and Disability
Break
Interactive Patient Scenario Stations
1st Rotation
2nd Rotation
Lunch
3rd Rotation
4th Rotation
Summary
Written and Practical Skills Evaluations
15 minutes (8:00am)
30 minutes (8:45am)
30 minutes (9:15am)
60 minutes (9:45am)
15 minutes (10:45am)
45 minutes (11:00am)
45 minutes (11:45am)
60 minutes (12:45pm)
45 minutes (1:45pm)
45 minutes (2:30pm)
30 minutes (3:00pm)
120 minutes (3:30pm)
PHTLS
th
7
Edition
Instructor Program
Overview
Instructor Program
• Revised Slides
– Administrative Overview
– Teaching Methodology
– Instructor Coordinator
– PHTLS Course Content Delivery
• Incorporates revised Provider, Refresher, TFR,
and TCCC Programs
Trauma First Response Course
Focus Audience
• First Responder
• Police Officer
• Firefighter
• Rescue personnel
• Safety Officer/Industrial
Responder
• CERT
Objective
• Teach the principles of PHTLS to those
who care for the patients first
• Help them prepare to care for trauma
patients while awaiting transport or
serving as part of the transport team
TFR Objectives
continued
• “Stresses the core PHTLS principles to
those who have not had EMT or
advanced prehospital training”
• Designed for the type of care first
responders render while awaiting
transport
Nicholas Senn, M.D.
American Surgeon (1844-1908)
“The fate of the wounded rests
in the hands of the one who
applies the first dressing”
Who Can Teach Trauma First
Response
• Any Current PHTLS Instructor
PHTLS bringing care to the
trauma patient…..
…at every level
Tactical Combat Casualty Care
Course Description
Initially developed by the military to
treat combat injuries sustained
while still under fire on the
battleground. Also teaches how to
render care when the battlefield
scene becomes a little bit more
secure and also how to evacuate
the casualty under potentially still
dangerous conditions.
Course Layout
• 16 Hours
• 2 Days
– Multiple Short Lectures
– Multiple Skill Stations
Care Under Fire
• Fire Power Supremacy
• Mission Critical Decisions
• Moving Casualties
• C.A.T.’s
• C-Spine Stabilization
TCCC
To become a provider you must
participate in a 16 hour TCCC
provider course
TCCC
To become a TCCC instructor you must
first be a TCCC Provider be a PHTLS
instructor and than be monitored
teaching a provider course by affiliate
faculty
TCCC
To become a TCCC site you must be
monitored teaching a TCCC course once
you have met all the other
requirements
PHTLS:
Research and Topical Reviews
Topical Hemostatic Agents
• HemCon
– ChitoFlex
• Wound Stat
– U.S. Army stopped use in 2009
• QuickClot
– Combat Gauze
PreHospital Tourniquets
• 6 articles reviewed from major journals
– Primarily military data
– Survival benefit if placed prior to the onset of shock (96%
vs 10%)
– Very low rate of complications (<1%)
• PHTLS recommendations:
– Indicated if direct pressure or pressure dressing fails
– Place prior to extrication and transport
– Additional tourniquet should be placed if bleeding
continues
– Safe, easy to apply, and saves lives
Spine Immobilization in
Penetrating Trauma
• Current standard – immobilize victims of penetrating
trauma with spine board ± cervical collar
• What is the data to support this?
• Consequences of spinal immobilization
• Damage is done at the time of injury and does not
worsen during transport or hospitalization
Spine Immobilization in
Penetrating Trauma
• Reviewed 16 papers
• No data to support the use of spinal immobilization in
patients with isolated penetrating head wounds
• No data to support the use of spinal immobilization in
patients with penetrating injuries to the neck or torso
unless a neurological deficit is noted
• Immobilization should not be done at the expense of a
good examination or an intervention for life
threatening injuries.
Future Topics
• PreHospital fluid resuscitation
• PreHospital airway interventions
• PASG
Trauma Case Study Presentation
2011 Annual South Central Kansas Trauma Region (SCKTR)
General Membership Meeting
April 26, 2011
Stacy L. Dashiell, MD
Family Medicine Physician
Sterling Medical Center and
Rice County Hospital District #1
Pre-Hospital (Rice County EMS)
• Called to the home of an 87 y/o M
– Found on the floor of a farm outbuilding by family
• Call received at 18:35; on the scene at 18:51
• Pt found sitting on the floor in the middle of
an unheated building, cold and confused
• IV access obtained—warmed NS started
• Spinal immobilization and oxygen
• Transported to Rice County District Hospital #1
Initial Hospital Presentation
• Arrived via EMS at 19:25 (~50 min since call)
• CC: “I’m cold.”
• HPI: Thought he had gotten “tangled in his
clothes” and fallen. Family found him and
were unable to get him up—called EMS.
Unsure how long he had been down—around
3-4 hours. Initially c/o back pain and nausea.
Primary Survey
• A: No airway obstruction; talking; NAD
– C-collar and spine board in place
• B: Non-labored speech; equal chest rise
• C: Pulses full; no obvious bleeding other than
minimal bleeding from R ear; extremities cold
• D: Drowsy but easily arousable; pupils equal but
sluggish; moves all extremities
• E: Exposed in segments to prevent further
hypothermia—no obvious trauma; log rolled, no
vertebral tenderness—cleared from spine board
Initial Hospital Physical Exam
•
•
•
•
•
•
•
•
•
•
•
•
•
19:30 VS—90.0 Ax, 114/66, 89, 20, 87% on 2L
Gen: alert but slow to respond, shivering
Head/neck: No obvious trauma, non-tender, trachea midline
Eyes: PERRL but sluggish, EOMI
Ears: Blood from R ear, unable to visualize TM, no obvious trauma
Nose/throat: No obvious trauma; airway normal.
CV/Lungs: RRR w/o murmur, CTA bilaterally
Chest: No obvious trauma, ttp over R chest wall (noted later)
Abd: S/NT/ND, No obvious trauma
Neuro: no focal deficits, speech slow; follows commands
Skin: Intact, cool to touch
Back: No vertebral point-tenderness, mild ttp throughout
Ext: Atraumatic, pelvis stable, no pedal edema, cool
Patient Information
• ROS: initially denied SOA, CP or palpitations,
chronically hard of hearing, generalized
weakness, frequent falls recently
• PMH: HTN, BPH, chronic prostatitis, HLP
• PSH: ankle surgery, cataract surgery, TURP
• Meds: hydrocodone/APAP, trimethaprim/sulfa,
meclizine, omeprazole, lisinopril, lovastatin,
diazepam, sertraline, saw palmetto, calcium
• Allergies: PCN
Treatment in ER
• 19:30 Bair Hugger warming unit and warm
blankets
• PTA Warmed normal saline via 20 g
– BP down to 88/45 at 1940
– Warmed normal saline bolus via 18 g at 1945
•
•
•
•
•
19:45 labs obtained
19:50 CT head/neck obtained
20:10 ondesetron administered
20:20 EKG obtained
20:50 morphine administered
Initial Labs/ EKG
• 19:45 Labs
– CBC: WBC=25,900
– CMP: glucose=208, BUN=29, Cr 1.7, Na 144, CO2=22,
remainder normal
– SOA Panel: Troponin <0.05, CKMB 13, CPK 662,
Myoglobin >500, D-dimer >5000, BNP 21
– UA (cath specimen): 3-5 WBCs, >25 RBCs, many
bacteria, many hyaline casts
• 20:20 EKG: NSR, rate 75, R BBB, no acute ST seg
changes
Initial Imaging
• 20:10—CT imaging completed and films sent
• Additional soft tissue windows requested
• 22:10—NightHawk reports finally available
– 2 hour delay
While waiting for CT reports…
• 20:35 Attempt to wean O2 as patient becomes warmer
and unable
• Patient becomes more alert and begins to recall he was
working on the back of a grain truck and fell off the
tailgate onto the floor
• Patient begins to complain of R chest wall pain
• 21:00 pCXR obtained: R lateral 2nd-5th rib fracture; ???
apical pneumothorax, no midline shift (my read)
– Radiologist’s report (available the following day):
• Acute fx of the R lateral 2nd-5th and 8th ribs; old posterior rib fx
• Tiny right apical pneumothorax
• Probable non-displaced fracture of the right body of the scapula
CT Reports Available
• CT Head: Soft tissue injury with no acute
intracranial findings. Fluid/blood within the right
mastoid air cells and middle ear cavity as well as
the external canal; chronic sinusitis.
– Soft tissue window settings requested for addendum
– Addendum negative for acute epidural hematoma
• CT Neck: No acute fracture or subluxations.
– Small right apical pneumothorax with possible
hydrothorax
Transfer Made
• 22:25 Spoke with internal medicine physician on call for
patient’s PCP at Promise Regional
– Described case and negative CT findings but questioned
whether a higher level of trauma care might be indicated
– Patient accepted at PRMC with no further orders
• 22:47 EMS arrived hospital for ALS transfer
• Status at time of transfer:
–
–
–
–
VS: T 98, 126/64, 75, 20 96% on 6L
Alert and oriented, conversing
Pain and nausea controlled
No active bleeding from R ear
• 23:00 Patient left the facility (~3 ½ hours after arriving)
Skilled Care
• 1-25-11 Transferred from Wesley back to Rice County
District Hospital for skilled care
– s/p ORIF R anterior column acetabular fracture
– Slow progress with PT/OT
– CT scan reviewed by neurosurgeon, basilar skull fracture
stable
• 3-4-11 Pt transitioned to intermediate care as PT
progress at a plateau until able to bear weight
• 3-19-11 Resumed skilled care once able to bear weight
– Intermittent oxygen requirements throughout stay
• 3-31-11 Transferred to Promise Regional Medical
Center for hypoxemia, pneumonia, CHF
South Central Regional Trauma
Council General Membership
Meeting
April, 26th, 2011
87 Year Old Male
2225 Lyons physician contacts Internal Med
provider on call for primary.
Dx: hemotympanum R, blood in mastoid air
cells, hypothermia, rib fractures with
pneumothorax R.
2247 EMS arrives at facility for transfer.
87 Year Old Male
2356 Pt arrives at PRMC- Hutchinson ICU
0027 Vitals:



B/P: 159/75
Resp: 20
Temp: 98.8 Oral
Pulse: 69
SaO2: 96/ 6L/ NC
0045 Primary care physician at bedside
H&P Plan: “Consulted surgery and ENT. We are
going to repeat his chest x-ray now and again in
the morning.”
87 Year Old Male
0125 Surgeon on phone inquiring about
admission cxr results. Rib fractures
identified at this time without visualization
of pneumothorax.
87 Year Old Male
0131 Orders:
CXR portable now
 Consult: Surgeon
 Consult ENT
 Protonix 40 mg IV qd
 Profile A, CBC in am Tuesday
 UA

87 Year Old Male
0136 Orders:
CXR approx 6 am portable
 IV NS @ 50cc/ hr
 MS 1-2mg IV q hr prn
 Zofran 4mg IV q 8 hrs prn
 Accucheck ac & hs & prn, SSI low dose

0836 PCP evaluates pt. Lab ordered for next
day, Regular diet.
87 Year Old Male
0836 Orders:
CT of head, chest, abd & pelvis ASAP. May
decrease IV contrast dose due to elevated
creatinine.
 Increase NS to 200cc/hr for 5 hrs then 100ml/
hr.

87 Year Old Male
CT head

acute nondisplaced fracture mastoid bone extending
cephalad into the right parietal bone
CT chest





Comminuted non-displaced fx right scapula
Nondisplaced fx right anterior first rib
Mildly displaced fracutres of the right posterior and
lateral 2nd through 12th ribs
right pneumothorax 10-15%
Bilateral lower lobe atelectasis
87 Year Old Male
CT abd/ pelvis



Comminuted, mild to moderately displaced mildly
distracted intraarticular fx of the right superior
acetabulum, which extends into the right iliac wing.
Mild retroperitoneal hemorrhage extends into the pelvis
from right transverse process fractures.
Moderately displaced right transverse process fractures
of L1 through L5.
Findings were discussed with surgeon
approximately 10:45.
87 Year Old Male
1115 Surgeon in room explains results to pt
and need to transfer
1120 20 Fr chest tube placed to pt R lateral
chest with dark red drainage noted.
1231 Pt dismissed per EMS to Wesley
Medical Center
87 Year Old Male
Pt was transferred from Wesley to Lyons for
skilled care.
3-31-11 Transferred to Promise Regional Medical
Center for “development of abnormal chest x-ray
and hypoxemia”.
Dx: Hypoxemia, Pneumonia, CHF.
Treatment: IV antibiotics, Diuretics,
Bronchodilators
4-8-11 Pt dismissed to nursing home
87 Year Old Male
Potential Complications:
Missed injuries at initial referral site
Missing EMS reports from referral site
Transfer to non-surgeon
Greater than 6 hour transfer out of facility
87 Year Old Male
Process Improvement:
Developing process to avoid non-surgical
admissions by house supervisor intervention.
 House supervisor will speak to referring facility
for EMTALA to ensure proper physician is
admitting.

Wesley Medical Center
Level 2
1/18/2011
W.N.
87 y.o. male
WMC Trauma Resuscitation
• 1335 pt arrives to trauma room
• V.S. B/P 127/62 HR 82 RR 18 Sa02 95% on 02
@6LNC Temp 98.3 oral GCS 15
• Pt placed in supine position C-collar placed for
c/o neck pain, NS infusing @ 200cc/hr, foley to
DD, chest tube in place with 105 cc drainage
noted
• Ortho @ bedside pelvis x-ray reports a Right
Ilium fracture
WMC Trauma Resuscitation
• CXR report : The chest tube is seen overlying
the right chest. A trace pneumothorax is seen
medially. There are multiple rib fractures on
the right of at least the 3rd through 8th ribs.
Patchy densities are visualized bilaterally that
may be due to atelectasis or contusions. The
heart size is upper limits of normal.
• CT C-spine negative
WMC Trauma Resuscitation
• CT T-spine reports Multiple nondisplaced rightsided rib fractures from the seventh through the
twelfth posterior ribs. Small right-sided pleural
effusion, with a right-sided chest tube placed
posteriorly approaching the right apex. There is a
small anterior pneumothorax that is incompletely
evaluated.
• CT L-spine reports Moderately anteriorly
displaced fractures of the right-sided transverse
processes of all lumbar vertebrae. Right-sided
iliopsoas hematoma.
WMC Trauma Resuscitation
• CT pelvis reports Mildly comminuted, mildly displaced
fracture through the right iliac wing extending through
the anterior column. Lateral diastases of the anterior
fracture fragment at the anterior column of
approximately 7 mm. The femoral head is well aligned
with the acetabulum. No intra-articular bony fragments
identified. The remaining pelvic rim appears intact.
Multiple intramuscular hematoma identified, more
specifically hematoma of the right-sided iliacus,
iliopsoas, and the right-sided obturator internus. Small
amount of free intraperitoneal fluid, with extension
into the right inguinal canal, and to rectus fascia.
WMC Trauma Resuscitation
• CT right shoulder reports Minimally displaced
comminuted fracture of the inferior scapular
wing. No significant adjacent soft tissue
swelling. No hematoma is evident.
• Dilaudid 0.4 mg IV given total for pain control
• 1725 pt transferred to SICU
WMC SICU 1-19-2011
• Pt to OR for Open reduction internal fixation of right
anterior column acetabular fracture using the lateral
window of an ilioinguinal approach
• MRI C-spine reports Multilevel degenerative changes of
the cervical spine. These are most prominent from C3C4 through C7-T1 with moderate-severe central canal
stenosis at these levels. Severe neuroforaminal stenosis
is also seen at multiple levels, as above. Mild
prevertebral edema extending from C2 through C7. No
epidural hematoma or ligamentous injury. No acute
fracture or dislocation of the cervical spine.
• C-Collar Dc’d
WMC SICU 1-20-2011
•
•
•
•
•
•
O2 SATS 98% on 5L/NC
PCA for pain control
Minimal chest tube drainage
Speech therapy working with patient
Transferred to trauma surgical floor
Dislodgement of chest tube from drainage system
noted Stat CXR reports : Right chest tube is in
stable position. Marked interval improvement of
the left airspace opacity. No pneumothorax.
WMC SICU 1-21 & 22-2011
• Intermittent confusion noted
• OT & Speech working with pt, diet advanced
• Pt noted to have Urinary retention per bladder scan
Foley placed
• Thrombocytopenia noted with platelet count 105
• Case management making arrangements for pt
transfer to Lyons swing bed
• Sa02 90% on 9 liters of 02, IPPB treatments &
aggressive pulmonary toilet treatments started
• CXR X2 stable, Chest Tube Dc’D
WMC SICU 1-23 & 24-2011
•
•
•
•
PT working with pt
Platelet count increased to 202
B/P 197/86
CXR reports Significantly improved aeration in
the lungs bilaterally especially on the right
with multiple right-sided rib fractures again
noted. No pneumothorax
WMC SICU 1-25-2011
•
•
•
•
B/P 149/68 pt requires 4 liters 02 per nasal cannula
Pt Dc’d to Rice County Swing Bed Skilled Nursing Unit
ISS 17 TRISS 95%
Discharge Diagnoses:
–
–
–
–
–
–
–
–
–
status post fall with concussion
Right hemopneumothorax
Rib fractures
Right transverse process fractures L1 through L5
Right iliopsoas hematoma
Right scapular fracture
Thrombocytopenia
Acetabular fracture
Right ilium fracture
Case Report
James M. Haan MD FACS
Medical Director
Via Christi Regional Medical Center:
St Francis
The Patient
•
•
•
•
45 male fall 45 ft oil rig
HD stable
Possible LOC
Injuries on X-Ray
–
–
–
–
Grade 2/3 Liver
Renal Laceration ?
Open femur Fx
R Clavicle FX
On Arrival
• Hemodynamically Stable
– 20 110 147/89
• Femur Splinted
• Minimal RLQ pain
– FAST negative
• Resuscitation
– 2 L crystalloid
– 1 of 2 PRBC
Outside Hepatic
Contrast Images
Renal
True Injury: Femur Fx
R Clavicle/Rib Fx
Hospital Course
• Transfusion 1 unit completed
– 2 unit returned Red cross
• OR for ORIF of femur
• R Clavicle delayed ORIF
Summary
• Resuscitation Issues
– Limited/Hypotensive resuscitation
– Blood Bank Local Resource Issues
• Education
– RTDCC
– ATLS
– Regional Peer
Summary
• Outside Imaging can safely be used BUT
• Imaging Often Limited by
–
–
–
–
Artifact
Lack of IV contrast/poor timing
Incorrect protocol
Software issues
COMMUNITY HEALTH
ASSESSMENTS:
Sara Roberts, MPH
Director of Rural Health
Bureau of Local and Rural Health
PRESENTATION TAKE-A-WAY

Understand:
The Community Health Assessment requirements
for Hospitals and Local Public Health; and
 The Core Elements of a Community Health
Assessment


Aware of the state-level effort to build
resources and tools to support local
community health assessments
HOSPITAL’S PERSPECTIVE –
The Patient Protection and Affordable Care Act
creates new IRS Code Section 501(r) which imposes
4 new requirements on tax-exempt hospitals.
CHARITABLE HOSPITALS MUST:

Complete Community Needs Assessment

Meet Financial Assistance Policy
Requirements

Adhere to Limitations on Charges

Follow Billing and Collection Practices
PATIENT PROTECTION AND
AFFORDABLE CARE ACT REQUIREMENTS




Hospitals must adopt and implement a strategy
to meet the community health needs.
Assessment must input from persons that
represent the “broad” interest of the community
serve and must include public health experts.
Hospitals must report how the organization is
strategically addressing the needs identified.
Requirement applies to tax years that start after
March 23, 2012.
Resource Link:
http://www.ruralcenter.org/sites/default/files/PPACA%20T
ax%20Exempt%20Hospital%20Status%20Requirements_
0.pdf
LOCAL PUBLIC HEALTH’S
PERSPECTIVE Public Health Accreditation Requirements




Conduct community assessments focused on
population health status and public health
issues
Engage with the community to identify and
address health problems
Develop public health policies and plans
Promote strategies to improve access to
healthcare services
Resource Link:
http://www.phaboard.org/assets/documents/PHABLoc
alJuly2009-finaleditforbeta.pdf
DEFINING:
COMMUNITY HEALTH ASSESSMENTS



The foundation for improving and promoting
the health of community members.
It is a "systematic collection, assembly,
analysis, and dissemination of information
about the health of the community.
A community assessment team looks at
community assets, strengths, resources, and
needs.
Resource Link:
http://www.healthycarolinians.org/assessment/guidebo
ok.aspx
Resource Link:
http://ctb.ku.edu/en/default.aspx
COMMUNITY HEALTH ASSESSMENTS
‘JARGON’ AND ‘APPROACHES’



Assessing Community Needs
Community Benefit Assessment
Conducting Environmental Scans
Various Approaches by Organizations:





Community Health and Programs Services (CHAPS)
Assessment
Mobilizing for Action through Planning and Partnerships
(MAPP)
Catholic Health Assn - Healthy Community Institute Model
Rural Health Works Community Engagement
YMCA Community Healthy Living Index
COMMUNITY HEALTH ASSESSMENTS
THE BASICS
Resource:
Kansas Association of Local Health Departments
WHY ARE COMMUNITY HEALTH
ASSESSMENTS IMPORTANT?
We Know:




Actions Should be Responsive to Local
Community Needs
Data Should Drive Decisions Made
Assessment is one-part of a Continuous
Process - Community Improvement
Planning, Quality Improvement
The Collective Effort is Stronger than
Individual Effort
WHY ARE COMMUNITY HEALTH
ASSESSMENTS IMPORTANT?
Trauma:
 Essential piece in to the community’s
local health system
 Invested in improving the quality of
health of the community
BEING INVOLVED IN COMMUNITY
HEALTH ASSESSMENTS
Potential Benefits:



Network Opportunities with other health providers
and community members
Increased Community Awareness of the Trauma
system as a Key Resource
Community Support for Trauma systems
development and injury intervention
initiatives
PUBLIC HEALTH AND HOSPITAL
COLLABORATION

Resolution Signed
between the Kansas
Hospital Association
(KHA) and the Kansas
Association of Local
Health Departments
(KALHD)
PUBLIC HEALTH AND HOSPITAL
COLLABORATION

KHA Community Needs Assessment Workgroup


Workgroup Charge: Research, review, and recommend
options and strategies that will assist providers in
meeting the community needs requirements
Development of Supporting Information Systems



Dashboard-style reports to look at 50-60 core data
measures
System will be maintained by KDHE
Resources to look for evidence-based practices
STATE COLLABORATION

(CONTINUED)
Kansas State Research and Extension

Kansas Rural Health Works
Resource dedicated to helping rural communities build affordable
and sustainable local health care systems.
http://krhw.net/index.html

University of Kansas

The Community Toolbox
Promoting community health and development by connecting
people, ideas and resources
http://ctb.ku.edu/en/default.aspx
DISCUSSION AND FEEDBACK
Contact Information:
Sara Roberts
Office of Rural Health
[email protected]
785/291-3796