State Trauma Advisory Council Meeting
Tuesday, June 6, 2006
MDH Snelling Office Park - Red River Room
Members Present: John Bowar, M.D., J. Kevin Croston, M.D., Robert Dahm, Jane Gisslen, R.N., William Heegaard, M.D., Mark Larkins, M.D., Timothy LeMieur, M.D., Mark Lindquist, M.D., Dennis Miley, Jeffrey Schiff, M.D., Linda Vogel, R.N., Mike Wilcox, M.D.
Members Absent: Tom Hock, R.N., P.A., Gary Pearson, Marc Swiontkowski
MDH Staff: Chris Ballard, Cirrie Byrnes, Jo-Ann Champagne, Cutis Fraser, Tim Held, Mark Kinde, Diane Mandernach, Mark Schoenbaum, Pat Tommet
Audience: Carol Immermann, Brenda Anderson, Karie Pearce, Laurel Anderson, Val Kriegler, Lisa Job, Debra Esse, Pat McCauley, Elaine Stevens, Molly O’Brien, Sherry Berndt, Darel Radde, Art Ney, MD
Call to Order, Welcome and Introductions
Chair J. Kevin Croston, M.D., called the meeting to order at 12:40 p.m. He introduced and welcomed Commissioner Dianne Mandernach, highlighting her key support and role in passing last year’s trauma legislation. Following the Commissioner’s remarks the STAC and audience were individually introduced.
Dianne Mandernach, Commissioner, Minnesota Department of Health, discussed her support for a statewide trauma system. She took note of two key strengths of the system’s design – it’s inclusion of all hospitals and it’s recognition of the crucial role that small rural hospitals have in the initial management of trauma patients. The Commissioner commended the progress and work of the STAC and said she looks forward to being part of future deliberations.
Approval of March 10, 2006 STAC Meeting Minutes - Minutes were approved as written.
Small Hospital Improvement Program (SHIP) Grant - Mark Schoenbaum, ORHPC Director
This grant is available through the Office of Rural Health and Primary Care to rural hospitals with 50 or fewer beds. Monies can be used to cover trauma designation related expenses. Mr. Schoenbaum encouraged anyone fitting the criteria to apply for a grant through the ORHPC.
MNTrauma (state web-based trauma registry)—Tim Held
MNTrauma is completed, tested, and launched. The only required equipment is a computer with internet connection. Curtis Fraser, MDH IT staff commented that the individual hospitals can query their own data relatively easily. More in-depth Ad Hoc queries will require greater familiarity with the product. ImageTrend, Inc., has developed on-line tutorials for users plus MDH staff are committed to providing individual support as necessary.
National Foundation for Trauma Care Site Surveyor Workshop—Tim Held
This national site surveyor workshop is designed for individuals who will conduct state-based levels III and IV site reviews. The course will be hosted at Regions Hospital, St. Paul, on June 25.th. MDH has grant money set aside to send nine people. These individuals have been chosen and will work with MDH to develop an abbreviated homegrown course for future site reviewers.
MDH Office of Emergency Preparedness – Tim Held
Grant money from the Bioterrorism Hospital Preparedness Program (BHPP) has supported the development of the state trauma system in the past. This federal grant is up again for renewal. MDH is looking at how the trauma system can support the new grant requirements.
Conflict of Interest / Ethical Behavior Statement—Tim Held
The STAC approved the Conflict of Interest / Ethical Behavior Statement and Dr. Croston instructed members to sign their copy and turn them in to MDH staff.
Level III Surgeon Response Criteria
Dr. Heegaard opened the discussion with an explanation of the Minnesota Academy of Emergency Physicians’ proposed language change to the 30 minute response time for Level III surgeons. A question was also raised about when the 30 minute countdown begins. Concern was expressed that calling a surgeon in for every patient with an injury and a GCS <8 would result in a great deal of over triage since many inebriated patients meet this criteria. Further, there was discussion about how to address the differences between the role of the rural general surgeon providing trauma care vs. the role of the general surgeon at trauma resuscitations in the outer-ring suburban hospitals.
It was agreed that the same criteria are needed for all Level III participants throughout the state and that the criteria needs to be simple. In addition, all cases meeting the criteria need to be reviewed at the local level. After a long and lively discussion, with audience participation, the following motions were passed:
Dr. Schiff moved / Dr. Bower seconded that under criteria number 3, “primary etiology” replaces “mechanism.” Motion passed.
Dr. Wilcox motioned / Dr. Heegarrd seconded that “within 45 minutes” be added to the parenthetical statement in criteria number 3. Motion passed.
There was also a motion / second that in criteria number 2, “penetrating trauma” be substituted for “gunshot wound.” Motion passed.
With these changes the final minimum criteria for Level III surgeon response to trauma team activations are:
“The minimum criteria for surgeon response to the resuscitation are (1) respiratory compromise/obstruction and/or intubation (2) penetrating trauma to the abdomen, neck or chest (3) Glasgow coma scale (GCS) < 8 with a primary etiology attributed to trauma (unless transfer out is expected to occur within 45 minutes) or (4) two consecutive, pre-hospital systolic blood pressures less than 90 in an adult or age-specific hypotension in children as follows:
Dr. Schiff moved acceptance of this language. Dr. Bowar seconded; the motion passed unanimously.
Ad Hoc Designation Work Group Report and Recommendations
Mr. Miley reported on feedback from a small committee of rural hospital administrators who met to review and comment on the proposed application material and criteria. There was some concern that the emergency department provider response time criteria of 15 minutes is not consistent with the 30 minute timeline required in the federal regulations (Medicare) for Critical Access Hospitals, of which there are 80 in Minnesota. There were also questions about the extent of educational requirements for nurses, and whether the STAC is the proper place to deal with medical helicopter issues. There was also an expressed need to educate hospitals on how to access and use MNTrauma.
Linda Vogel, RN, began her report with an overview of the newly proposed and simplified application and application guidance documents for Levels III and IV. She then reviewed all the Ad Hoc Designation Subcommittee’s recommendations. The first recommendation is to require a medical director for the trauma programs at level IV trauma hospitals. Mr. Miley explained how requiring the title “Medical Director” could create a JCAHO issue and new costs for small hospitals.
Dr. Schiff moved / Dr. Heegaard seconded that the recommended version #1 language be changed from “medical director shall be a physician” to “physician advisor” for level IV criteria. Motion passed.
A related discussion followed to clarify the certifying body for physicians who are board certified in emergency medicine. Dr. Heegaard moved / Dr. Schiff seconded that “board certification in emergency medicine” be clarified as an American Board of Emergency Medicine (ABEM)-approved certification. Motion passed. This change will be reflected throughout all the application materials.
Ms. Vogel, RN, highlighted an inadvertent omission and typo in the original criteria. First, the addition of a ventilator needs to be added to the equipment list for level IIIs. Note: the existence of a ventilator is clearly referenced in Respiratory Therapy Capabilities. Second, change level IV locum tenums educational requirement under Clinical Qualifications from “not applicable” to “essential.” Note: the inclusion of level IV locums in the training requirement standard is referenced in Clinical Capabilities: Emergency Medicine.
Ms. Vogel, RN, also pointed out the need to specify a parameter for requiring and measuring the emergency department provider response time. The current criterion requires response to the emergency department within 15 minutes but does not specify when the clock starts. After much discussion, Dr. LeMieur moved / Ms. Gisslen, RN seconded the following emergency department provider response standards: “Level IIIs within 15 minutes of EMS notification; and Level IVs within 30 minutes of EMS notification.
Following, Dr. Heegaard moved / Mr. Dahm seconded that the emergency department provider response standards be incorporated as a required performance improvement filter for hospitals. Motion passed.
The Ad Hoc Work Group recommended several options for reviewing applications, site review reports, and in making recommendations to the Commissioner for designations. The STAC adopted option “C” for both Levels III and IV as presented in the handout material. The only modification was to have staff do the initial screening of applications vs. a sub-committee of the STAC.
The STAC approved the site visit team make-up, reporting procedure and reviewer qualifications as proposed by the Ad Hoc Work Group.
Mr. Held read portions of an email from Dr. Swiontkowski (unable to attend the meeting) which outlined his concern about permitting general surgeons to perform orthopaedic surgical care. After a brief discussion the consensus was that it is incumbent upon hospitals that they credential only general surgeons to perform othopaedic surgery who are skilled and experienced at it, that to immediately prohibit this would create an immediate hardship in many rural hospitals, and that this custom is phasing out through attrition so it should not be a long term issue. It was decided to not change the existing permissive criteria.
Mr. Miley moved / Dr. Wilcox seconded to approve the new Level III and Level IV applications containing the newly approved criteria and application review process. The motion passed unanimously.
-10 minute break-
Disaster Planning and Preparedness
Pat Tommet, MDH Bioterrorism Hospital Preparedness Program (BHPP) Supervisor, presented an overview of the BHPP program and forthcoming federal requirements that are germane to the state trauma program. She concluded by suggesting that the STAC may be able to assist the BHPP through recruitment and development of Hospital Response Teams and in recruiting a Regional Medical Director for the BHPP regional systems in southeast, southwest, south central, and west central areas of the state.
Data/QI Work Group Update
Dr. Schiff updated members on the activities thus far in preparation for the first Work Group meeting later in July. He presented two non-controversial (simplifications) changes to the existing Minnesota Trauma Registry Inclusion Criteria. Currently, the inclusion criterion begins with patients who have a primary OR secondary discharge ICD9-CD diagnosis code from the approved list of codes. Dr. Schiff proposed removing “or secondary.” Second, under the transfer criteria, to add “for trauma care” in order to clarify that only these transferred patients belong in the trauma registry. A motion and second were made to adopt these changes. Motion passed. Other related suggestions were referred to the Data/QI Work Group for discussion.
No-Fault Auto Insurance
The Council discussed recent developments regarding No-Fault auto insurance.
Wrap-Up and Next Meeting
With no further business, the meeting was adjourned by Dr. Croston at 4 p.m.