Plan Summary

It is a well established fact that an organized system of care for injured persons reduces mortality and morbidity. Not only has it been shown that mortality and morbidity are reduced from such a system, injuries as a whole decrease due to organized prevention efforts. Injury is the leading cause of death in California between the ages of 1-34 years. The original trauma plan for the S-SV EMS region was approved by Emergency Medical Services Authority (EMSA) in 1994 utilizing a multi disciplinary trauma task force made up of system stakeholders. S-SV EMS received special grant funds from the State of California Emergency Medical Services Authority to develop the trauma plan. At that time with the help of consultants, an extensive needs assessment and inventory assessment of current resources was conducted documenting the current system in the S-SV EMS region and the challenge facing the region in implementing an inclusive trauma system. Because of projected volumes and population within S-SV EMS service area, the EMS Authority granted an exemption to the population requirement with the concurrence of the EMS Commission on the basis of documented local needs. Today the population of the region far exceeds the minimal number of 350,000 population within the service area negating the necessity for a State exemption.

Milestones/Accomplishments since the inception of the S-SV Regional Trauma Plan

• Development of the Statewide Trauma Task Force
• 1992 Development of 30 minute catchment area for trauma
• 1993-Development of the Pediatric Task Force
• 1993-Special Projects Grant for EMScan Data Collection software to be used for prehospital care quality improvement
• 1995-Contracted with Tri-Analytics for the implementation of the regional Collector trauma registry system
• 1995- Designation of Sutter Roseville Medical Center as a Level II Trauma Center
• 1996-1997-Development of Pediatric Critical Care Center designation
• 1997-Development of policies to include pediatric destination
• 1997- Special Projects Grant for Helicopter Dispatch Coordination
• 2001-Projected designation of Tahoe Forest Hospital and Rideout Memorial Hospital as a Level III Trauma Center
• 2001- Development of 45 minute catchment area
• 2001-Development of the Trauma White Paper CDC EMSA Preventative Health Care Block Grant #9056

The intent of this plan is to update the existing State approved Regional Trauma System Plan for Sierra-Sacramento Valley EMS Agency, in coordination with adjacent systems, with the continued goal of reducing the mortality and morbidity of injured patients in the Region. This Trauma Plan meets and or exceeds all the required State trauma regulations.

The Sierra-Sacramento Valley Emergency Medical Services (S-SV EMS) Agency is a regional multi-county Joint Powers Agency that serves as the local EMS Agency for the five counties of Placer, Yolo, Nevada, Sutter, and Yuba. Complete authority for planning, development, and implementation of all EMS components including regional trauma planning, with the exception of disaster planning, has been delegated to the Agency by all five member counties.

These counties encompass an area of some 4,671 square miles with a resident population of approximately 666,700 people. The region ranges from remote rural areas to large urban centers. Extremes of weather are characteristic of the area, which encompasses both the Sierra Nevada Mountains and the flat land of the Sacramento Valley Delta region. Two of the five counties are designated as rural. (See map Appendix #2)

The EMS system in the region consists of public and private Advanced Life Support (ALS) ambulance response. This is supported by simultaneous dispatch of Basic Life Support (BLS) and first responder fire department personnel.

The S-SV EMS region is serviced by six helicopter providers: CALSTAR, REACH, UC Davis LifeFlight, Flight Care, Care Flight, and CHP H20. All of the providers except CHP-H20 utilize Registered Nurses (RNs). These RNs work under standardized procedures developed and controlled by the air provider's medical director. CHP-H20 is an ALS rescue helicopter and has one licensed paramedic on board. The CHP paramedics are accredited in S-SV region and follow the S-SV Prehospital ALS protocols. CALSTAR is located in Placer County and provides air transport to the closest Level I & Level II trauma centers. The Sacramento County based UCDMC LifeFlight and REACH helicopters provide air transport services to the closest Level I or Level II trauma centers. Enloe Memorial Hospital Flight Care based in Chico and Careflight based at Washoe Medical Center in Reno, Nevada, provide air transport services to the closest Level I or Level II trauma center.
In September of 1999, the California Department of Forestry's Grass Valley Emergency Communications Center began to serve as the central coordination center for all helicopter resources in the S-SV EMS region. This system allows the Public Service Answer Point (PSAP) to request the most appropriate helicopter with a single phone call to Grass Valley ECC. Prior to September 1999, the dispatch of these aeromedical resources had been the responsibility of multiple PSAPs. The lack of coordinated helicopter response resulted in multiple resources being requested to the same event. No single PSAP could know the operational status of six helicopter providers without contacting each provider individually.

There are eight hospitals located within the S-SV EMS region. Sutter General Hospital is located in Sacramento County and provides base hospital service for the City of West Sacramento in Yolo County.

The following hospitals are full base hospitals that provide services to the region:

• Sutter Roseville Medical Center
• Sutter Davis Hospital
• Sutter General

The following hospitals are modified base hospitals that provide service to the region:

• Rideout Memorial Hospital
• Sierra Nevada Memorial Hospital
• Sutter Auburn Faith Hospital
• Tahoe Forest Hospital
• Woodland Memorial Hospital

Kaiser Roseville is a receiving hospital in the region. All base hospitals actively participate in the Continuous Quality Improvement process conducted in coordination with the Agency.

Current Status

Sutter Roseville Medical Center is the Regional ACS verified, S-SV EMS designated Level II Trauma Center. Sutter Roseville Medical Center was initially verified by the ACS in 1995 and designated that same year by S-SV EMS. ACS reverification occurred in January 2001 with continued designation awarded. The University of California, Davis Medical Center (UCDMC) located in downtown Sacramento, was designated by the Sacramento County EMS Agency under the auspices of that Agency's approved Trauma Plan. S-SV EMS Agency has recognized this designation through a contract with S-SV EMS. UCDMC provides primary trauma care to Yolo County and acts as a tertiary referral center for the entire region. UCDMC is an ACS verified and Sacramento County designated Pediatric Level I Trauma Center and Burn Center. Mercy San Juan Medical Center located in Sacramento County is ACS verified and designated by Sacramento County EMS as a Level II trauma center and provides service to residents S-SV EMS region. S-SV EMS recognizes the trauma care provided by these two centers. S-SV EMS has a contract with Mercy San Juan Medical Center to ensure the optimal care of trauma patients that are time closest for transport to Mercy San Juan Medical Center. The extreme eastern portion of the region borders on the state of Nevada. Typical patient flow from the Truckee area is to Washoe Medical Center in Reno. The State of Nevada has designated Washoe as a Level II Trauma Center. S-SV EMS recognized the designation of Washoe Medical Center by the State of Nevada. Under the S-SV EMS Trauma Plan, the base hospital physicians for the Washoe area will retain the ability to transfer patients directly from the field to this out-of -state facility.

Currently, S-SV EMS Regional Trauma Plan anticipates one (1) Level II trauma center located within the Region and three (3) Level III centers. Because of the strong effective triage criteria and the locations of the trauma centers, trauma patients typically bypass the other acute care facilities. However, if the Atrauma patient@ presents at one of these facilities they are immediately resuscitated, and stabilized for transfer to a trauma center. All facilities are required to have interfacility transfer agreements with the Level I and Level II trauma centers. Pediatric trauma care is provided by UCDMC as the Regional Trauma Center. S-SV EMS Policy #860 Trauma Triage Criteria (Appendix #1)- the following pediatric patients should be transported directly to UCDMC: Children thirteen (13) years of age or less, with a Pediatric Trauma Score of 8 or less. All children six (6) years of age or less, meeting Anatomic and/or Physiologic criteria. If a pediatric patient meets criteria for the direct transport to UCDMC, both the patient's condition is so critical that any additional transport time may jeopardize the patient's life transport the patient to the closest designated trauma center. S-SV implemented a Regional Trauma Registry in 1995, which provides the fundamental basis for Trauma System evaluation, performance and system planning.

Challenges to the System

The smaller facilities within the Region continue to experience concerns related to medical staff commitment and Level III designation. Tahoe Forest Hospital and Rideout Memorial Hospital have submitted applications and paid all required fees for designation. It is anticipated that the designation will be completed at Rideout by the fall of this year. Tahoe Forest as well as Sutter Davis are experiencing issues related to availability of surgical specialists willing to support the program.

Proposed Solutions

S-SV EMS is working with the California Assembly to draft legislation on funding issues. The issue of surgical commitment at all Levels of the trauma system is a national phenomenon and S-SV EMS will continue to provide technical assistance to assure a successful Level III designations at each location.

Organizational Structure

Regional EMS Agency

The S-SV Agency is a regional multi-county Joint Powers Agency that serves as the local EMS agency for the five counties of Placer, Yolo, Nevada, Sutter and Yuba.

The five counties have a combined resident population of 666,700 and a significant tourist population. Complete authority for planning, development and implementation of all EMS components including regional trauma system planning, except disaster planning, has been delegated to S-SV by all five member counties. The Governing Board of Directors for the Joint Powers Agency consists of a County Supervisor from each of the member counties.

System Management

As the Joint Powers Agency for the region, S-SV has the responsibility for planning, implementing and managing an inclusive trauma care system. The Agency Regional Executive Director and the Medical Director direct the medical and administrative aspects of the trauma system. All Agency staff, including the Regional Executive Director and the Medical Director, participate in system monitoring, evaluation and problem solving. The Associate Director and the Quality Assurance/Education Coordinator are integrally involved with the oversight of the Trauma Plan, the regional trauma registry and the regional Trauma Quality Improvement Program. They play a significant role in the development of area-wide trauma system education and prevention activities.

The Agency has a strong participatory regional committee structure composed of the Medical Control, Trauma Quality Improvement, Pediatric Advisory, and Helicopter Advisory Committees. These committees allow all stakeholders the opportunity to provide input into ongoing trauma planning and facilitate communication, awareness and commitment of all participants to the EMS process. Our Education/QI Coordinator and Disaster Coordinator attend the Sacramento County Medical Control and Hospital Council meetings and statewide EMSC, OES Region III and IV disaster planning meetings. Our Director and Associate Director serve on and attend several statewide committees - Interfacility task force, trauma task force, DHS Prevention 2000 Block Grant Funding, Vision Committees, Legislation, EMSC, EMSAAC, Data ad hoc, CDC Grant Review Committee. Our Medical Director is involved in many committees and is the Medical Director for Long Beach Memorial Hospital Emergency Department, Medical Director for Mercy Air ambulance service in Long Beach, Clinical Instructor, department of emergency medicine. Los Angeles County USC Department of Emergency Medicine, American Board of Emergency Medical examiner, Scope of Practice Committee, past chair, current member, CAL ACEP and on the Prevention Vision Group.

All significant changes or updates to the Trauma Plan occur with the assistance of the Trauma Quality Improvement committee. This is a closed protected meeting, which meets quarterly at one of the Level I or II trauma centers. This committee is composed of physicians and nurses from the designated trauma centers and all receiving centers in the Region. Additionally the medical directors from Sacramento and S-SV EMS are members. In addition to system issues the committee reviews trauma deaths and quality improvement data from the region supported by the trauma registry.

Needs Assessment

Planning Basis

In 1994, when the original trauma system plan was designed, the criteria considered included the: projected patient volume and number of trauma centers: California's Trauma Care System Regulations require no more than (1) Level I or II trauma center shall be designated for each 350,000 population within the service area. Where geography and population density preclude compliance with this subsection, exemptions may be granted by the EMS Authority with the concurrence of the Commission on EMS on the basis of documented local needs. This waiver was requested and granted in 1994 when the original S-SV Regional Trauma Plan was approved. It has long been the premise that each designated trauma center should receive a sufficient number of major trauma patients to maintain a high level of skill. The American College of Surgeons (ACS) suggests 1200 cases/year or each surgeon taking call should attend at a minimum 35 patients with an Injury Severity Score (ISS) of greater than 15. This standard has been incorporated in to the California Code of Regulations, Trauma Care System Regulations section ' 100260. The trauma regulations do not specify volume indicators for other than Level I trauma centers. Likewise, the ACS recommends the Performance Review process determine volume quality issues in Level II, III and IV centers.

Current Status

S-SV region does not have a hospital within the region that meets the requirements of a Level I trauma center. In 1994, the University of California, Davis Medical Center (UCDMC) located in downtown Sacramento, was verified by ACS and designated by the Sacramento County EMS Agency under the auspices of that Agency’s approved Trauma Plan. S-SV Region has recognized this designation and through an interagency agreement and an agreement with UCDMC Level I trauma care is afforded to the region. The original S-SV Regional Trauma Plan required an exemption because the population was less than 350,000 within the service area. Today the population of the service area is approximately 666,700 residents making the need for a waiver no longer necessary. Interstate 80 stretches for more than 100 miles directly through the S-SV EMS region with approximately 13,000,000 vehicles traveling to and from Lake Tahoe and Reno annually.

Since the original S-SV Regional Trauma Plan was implemented the population growth in the region has far exceeded the 350,000 population within the service area. Today the population of the service area is approximately 666,700 residents. In keeping with the core objective of an inclusive trauma system plan and the special needs of the Region we project the need for one (1) Level II trauma center and three (3) Level III centers in the region.

Resource availability to meet staffing requirements for trauma centers:

Since the original trauma plan was submitted, S-SV has designated one Level II trauma center at Sutter Roseville Medical Center. Sutter Roseville was initially verified by the ACS in 1997 and subsequently designated that same year by S-SV. Re-verification occurred in January 2001 with continued designation awarded. According to trauma registry data submitted to S-SV by Sutter Roseville for the time frame of January 1995 to August 31, 2001, 5,497 patients were admitted to the trauma service.

S-SV has received a proposal from Rideout Hospital to participate in the trauma system as a Level III trauma center. Tahoe Forest has also expressed a commitment to provide the same level of service. It is anticipated that both facilities will be designated by S-SV as Level III trauma centers by fall of 2001.

Mercy San Juan Medical Center located in the city of Carmichael in Sacramento County is designated by Sacramento County EMS as a Level II trauma center and provides service to residents of the S-SV region. As we recognize UCDMC, S-SV recognizes the trauma center designation process of our neighboring jurisdiction and recognizes the support and trauma care provided by these two centers. UCDMC, Mercy and Roseville all participate with the S-SV Region related to trauma system design, trauma data collection and performance improvement.

In order to be designated as a trauma center in the S-SV Region, each applicant must meet the standards for Level II and III trauma centers as published in the current addition of the Resources for the Optimal Care of the Injured Patient published by the American College of Surgeons, Committee on Trauma. These standards exceed the State trauma regulations.

Transport times: Injured patients will be transported to the nearest, highest Level of care. Because of the inclusive nature of the trauma system and the geographic challenges of parts of the S-SV region, patients may be resuscitated and stabilized at a hospital and transferred to a higher Level of care at the Level I or II trauma center. Transfer agreements are in place at all facilities.

Distinct Service Areas:

The five counties that constitute the primary catchment area encompass an area of some 4,728 square miles with a resident population of 666,700 people. The secondary catchment area consists of Sacramento and El Dorado Counties. The total population of Sacramento County is 1,223,499. Sacramento County encompasses approximately 994 square miles in the middle of the 400-mile long Central Valley. El Dorado County population is 156,299. This County encompasses 1805 square miles bordered by Lake Tahoe and Nevada on the east and reaching within 25 miles of the State Capitol in Sacramento.

In June of 2000, the S-SV EMS Medical Control Committee revised the catchment areas from 30 to 45 minute ground transport time for the triage of trauma patients. Specific geographic boundaries have been removed in deference to paramedics judgement with regard to weather, time of day, road/traffic conditions effecting transport time.

Designation of Rideout, Tahoe Forest and Sutter Davis as Level III trauma centers will not change catchment areas. The trauma triage criteria will still route patients with anatomic and physiologic criteria directly to the closest Level I or II trauma center. Currently patients that meet mechanism only criteria are routed to the closest hospital.

Coordination with neighboring trauma systems:

S-SV region coordinates with all neighboring trauma systems in particular Sacramento County EMS, El Dorado County EMS and the State of Nevada Statewide EMS.

Unique Issues/Needs Assessment

The Sierra-Sacramento Valley Emergency Medical Services region has many unique issues that make the adoption of standard trauma planning not feasible. The region is composed of five counties, Placer, Yolo, Nevada, Sutter and Yuba. These counties encompass an area of some 4,728 square miles with a resident population of 666,700. In 1999 the S-SV region was reported to have 26,754 fatalities or injured on 5,826 city, highway and county miles.

The majority of the region is rural with pockets or centers of high population density. In 1994 local county planners estimated that the entire region would experience a 50% increase in population for the region by the year 2010. The growth has occurred much quicker than anticipated. Therefore, any current planning must address an estimated population in 2010 of over a million residents. The geography of the region varies from the flat valleys of the highly agricultural areas of Yolo County, to the Sierra Nevada Mountains of the Lake Tahoe area. Two of the five counties are designated as rural counties. All five counties have a rural land mass of greater than 50%.

The region is traversed by a number of major Interstate and State Highways. Interstates include: 5, 99, and 80. Interstate 5 is the primary route north and south in California. Interstate 80 is the primary route east and west in Northern California. Not only do these major highways provide access to destinations east and north of the region, they lead to one of the state's major recreation areas, Lake Tahoe. Many thousands of drivers a day traverse the region’s many highways. It is important to realize these numbers reflect a tremendous population of people that are not only driving cars in the region but recreating as well. As people recreate in communities where skiing, hiking, mountain climbing, rafting, and bicycling is popular, the potential for injury is extremely high.

Trauma Care System Design

Overview of the Trauma System

The trauma system in the S-SV EMS region is based on an inclusive trauma model and incorporates every acute care facility in the region. Currently there are seven hospitals within the region providing care for injured persons and two designated trauma centers in other EMS regions providing trauma care to residents of the S-SV EMS region. Since the original trauma plan was submitted, S-SV has designated one Level II trauma center at Sutter Roseville Medical Center.

Sutter Roseville was initially verified by the ACS in 1997 and subsequently designated that same year by S-SV. Re-verification occurred in January 2001 with continued designation awarded. Adjacent to the S-SV EMS region in Sacramento County, UCDMC provides Level I trauma care, both initial stabilization and tertiary care. Through an exclusive contract with S-SV EMS, UCDMC provides primary trauma care to Yolo County and acts in a tertiary capacity for the entire Region.

Mercy San Juan Medical Center located in the city of Carmichael in Sacramento County is designated by Sacramento County EMS as a Level II trauma center and provides service to residents of the S-SV Region. As we recognize UCDMC, S-SV recognizes the trauma center designation process of our neighboring jurisdiction and recognizes the support and trauma care provided by these two centers. S-SV EMS has a contract with Mercy San Juan to ensure the optimal care of trauma patients that are time closest for transport to Mercy San Juan.

Tahoe Forest, Rideout and Sutter Davis have all expressed a commitment to become designated Level III trauma centers within the S-SV EMS region. Tahoe Forest and Rideout have submitted applications and paid all required fees for designation. It is anticipated that the designation will be completed at Rideout by fall of this year. Sutter Davis is experiencing issues related to surgical staff commitment. This is a common problem nationally and S-SV EMS will continue to provide technical assistance to assure a successful Level III designation.

The extreme eastern portion of the region borders on the state of Nevada. Typical patient flow from the Truckee area is to Washoe Medical Center in Reno. The State of Nevada has designated Washoe as a Level II trauma center. S-SV EMS recognizes the designation of Washoe Medical Center by the State of Nevada and under the S-SV Trauma Plan, the Base/Modified Base physicians for this area will retain the ability to transfer patients directly from the field to this out-of-state facility.

The Regional Trauma Plan suggests one (1) Level II trauma center located within the region and three (3) additional acute care facilities be designated as Level III centers. Because of the strong effective triage criteria and the locations of the trauma centers trauma patients typically bypass the other acute care facilities. However if the trauma patient presents at one of these facilities they are immediately resuscitated, and stabilized for transfer to a trauma center. All facilities are required to have interfacility transfer agreements with the Level I, and II trauma centers.

Trauma Center Requirement

In order to be designated as a trauma center in the S-SV region, each applicant must meet the standards for Level II and III trauma centers as published in the current addition of the Resources for The Optimal Care of the Injured Patient published by the American College of Surgeons, Committee on Trauma. These standards exceed the State trauma regulations as stipulated in Article 3 Sections100259 -100263. The ACS standards are very specific related to critical care capabilities, medical organization and management and quality improvement. The contracts with UCDMC and Mercy San Juan require both facilities to maintain trauma center designation through Sacramento County EMS Agency. Sacramento County EMS requires the Level I and II trauma centers to comply with the current published standards from the ACS.

S-SV has also specified additional trauma center requirements for the region. All trauma centers in the region shall have the following written policies in place and agree to the following requirements:

1. A written policy of non-discrimination, which includes: the fact that no patient entering under the trauma triage criteria will be denied care on the basis of race, creed, color, national origin, sex, or the ability to pay for care.
2. The trauma center shall accept for transfer all major trauma patients from within the region whose clinical condition requires a higher Level of care than can be provided by another facility.
3. A written transfer agreement with a trauma center of a higher Level providing for the transfer of patients for specified medical conditions.
4. The Agency will charge an annual fee for trauma center designation based upon analysis of its costs to manage and operate the system. The fee structure will be reviewed and approved by the Agency Governing Board of Directors. Designation as a trauma center will be contingent on payment of an annual fee. The monies collected shall be used solely to support the trauma system, in accordance with California laws
5. The trauma center agrees that it is in compliance with Government Code Section 8355 in matters related to a drug-free work place.
6. The trauma center will participate in the collection of data for the Regional Trauma Registry.

Injury Prevention

S-SV requires injury prevention activities in the contract with the trauma centers. Sutter Roseville, UC Davis and Mercy San Juan are active in the Safe Kids Coalition, Every 15 Minutes and providing bicycle safety with the neighboring fire departments. UC Davis Medical Center has a public education program relating to organ donation in English and Spanish.

Prehospital Care

The region is covered by public and private ALS ambulance response supported by simultaneous dispatch of BLS and first responder fire department personnel. Prehospital providers are currently trained in trauma triage and principles of field resuscitation of injured patients and meet all of the State requirements for education. All prehospital providers follow S-SV EMS Policy #860 to assure early notification of trauma centers if the impending arrival of trauma patients.

All ALS vehicles used to transport patients within the region are required to have two-way radios. Most ALS providers utilize cell phones in addition to mednet UHF radios. Existing policies and procedures provide for Base/Modified Base contact, standing orders and radio failure protocols that the paramedics shall follow in the event of a communication failure. All acute care facilities within the region are Base/Modified Base Hospitals and have the capability of communication with the prehospital providers in their area.

Six helicopter providers service S-SV EMS region: CALSTAR, REACH, UCDMC LifeFlight, Flight Care, Care Flight, and the California Highway Patrol H20. All of the providers except CHP-H20 utilize registered nurse. These flight teams work under standardized procedures developed and controlled by the air provider medical director. H20 is an ALS rescue helicopter and has one licensed paramedic on board. This paramedic is accredited in S-SV region and follows the S-SV Prehospital ALS protocols. In September of 1999, the California Department of Forestry's Grass Valley Emergency Communications Center began to serve as the central point of coordination for all EMS helicopter resources for the S-SV Region. S-SV obtained a grant from the EMS Authority (EMS-7039) to implement this system. This system allows the Public Service Answer Point (PSAP) to request from the Grass Valley CDF the most appropriate helicopter with a single phone call. Prior to September 1999, the dispatch of these aeromedical resources had been the responsibility of multiple PSAPs. The lack of coordinated helicopter response resulted in multiple resources being requested to the same event. In addition lack of coordination of EMS helicopters result in safety issues. No single PSAP could know the status of six helicopter providers without contacting each provider individually. This change is process has resulted in greater provider satisfaction and optimizes resources and improves the quality of patient care.

The Agency has implemented a state of the art prehospital data collection system. All prehospital ALS providers utilize a standardized EMS data collection form. The Agency can track trauma patients from the field through rehabilitation without duplicative data gathering.

Each of the acute care facilities in the Region with the exception of Kaiser Roseville acts as a Base/Modified Base Hospital for the prehospital providers in their region. Base/Modified Base Hospital services are provided via contract between the facility and the Agency. Each Base/Modified Base Hospital is required to have a Medical Director and a Base Hospital Coordinator. All Base/Modified Base Hospitals are accountable to the Regional Agency. Quality of care is reviewed on an on-going basis and retrospectively. The Agency maintains an advisory Medical Control Committee in which all Base/Modified Base Hospital physician and nurse coordinator representatives actively participate in the approval process of all procedures and policies for the prehospital care setting.

The contract between the Agency and UCDMC for the provision of Trauma Care for Yolo County provides for UCDMC to be the Trauma Base Hospital for prehospital units in Yolo County when the patient meets certain trauma triage criteria (See Trauma Triage Criteria Appendix #1). This allows for UCDMC to provide medical control and destination decision according to trauma triage criteria.

Projected Trauma Patient Volume

Based on trauma registry data we know the following trauma patient volumes. It is anticipated because of the population growth in the region the current volume will only increase.

Total Patients

* Represents Yolo County Patients Only. This number does not reflect the total volume of trauma at UCDMC.

In keeping with the core objective of an inclusive trauma system plan and the special needs of the region we project the need for one (1) Level II trauma center and three (3) Level III centers in the region. S-SV has major interstates and highways that have a large population traveling to major tourist area, thus increasing the population significantly. (See Map, Appendix # 2)

Resources Available to Meet Staffing Requirements for Trauma Centers

By using the services of the American College of Surgeons, S-SV EMS Agency assures a third party verification of the resources necessary to meet and exceed the standards stipulated in the State trauma regulations as Article 3 Sections 100259 -100263.

Coordination with neighboring Agencies

A contract was executed between the Agency and UCDMC, the designated Level I Trauma Center in Sacramento County, to provide primary trauma coverage to Yolo County. This contract has been in effect since September 13, 1993 and updated on a periodic basis. S-SV Trauma Triage criteria that defines trauma patients is specified in the contract. The S-SV contract with UCDMC for Trauma Care in Yolo County provides for the prehospital medical control by UCDMC for patients meeting the field triage criteria. Patients not initially meeting field triage criteria will be transported to facilities in Yolo County. Criteria for interfacility transfer of patients needing a higher Level of care are in place. UCDMC will act as a tertiary referral center to the facilities in Yolo County who receive injured patients needing a higher Level of care. (See UCDMC Contract Appendix #3)

S-SV has a contract with UCDMC for Level I pediatric trauma center for the five county region. In addition to the contract for tertiary trauma care with UCDMC, S-SV has contracts with UCDMC and Sutter Memorial Hospital as regional Pediatric Critical Care Centers. S-SV EMS contracts with Mercy San Juan for Level II trauma care for the few patients that are closer by transport time to the trauma center. Because of the proximity of S-SV to surrounding EMS Agencies and primarily because of patient referral patterns and patient flow patterns S-SV EMS works in collaboration not only with Sacramento County but El Dorado County as well to assure communication and to address system issues as they arise.

Transport Times/Service Areas

In June of 2000 the S-SV EMS Medical Control Committee revised the catchment areas from 30 to 45 minute ground transport time for the triage of trauma patients. Specific geographic boundaries have been removed in deference to paramedic’s judgement with regard to weather, time of day, road/traffic conditions effecting transport time.

Designation of Rideout, Tahoe Forest and Sutter Davis as Level III trauma centers will not change catchment areas. The trauma triage criteria will still route patients with anatomic and physiologic criteria directly to the closest Level I or II trauma center. Currently patients that meet mechanism only criteria are routed to the closest hospital.

Response Time Standards:

8 minutes - urban
10 minutes - suburban
12 minutes - semi-rural
20 minutes - rural

Pediatric Trauma Care

Pediatric care has long been a priority for the S-SV Region. The region has an extensive history of commitment to improving pediatric care and has played a key role in developing standards for pediatrics within our region that have become the model for many other EMS jurisdictions in California. Pediatric trauma is handled in several ways. UCDMC is designated by Sacramento County EMS Agency and verified by the American College of Surgeons as a Level I Pediatric Trauma Center. S-SV recognizes this designation and UCDMC functions as the Level I pediatric trauma center for the five county region. According to the Sacramento EMS Agency UCDMC meets all the criteria for a Level I Pediatric Trauma Center as specified in the trauma regulations Section 100261. This Level of service is also stipulated in contract with the S-SV EMS Agency.

Field Trauma Triage criteria preferentially route critically injured pediatric patients to the Level I Pediatric trauma center (UCDMC). (See Policy # 860 Appendix# 1)

Sutter Roseville Medical Center, the Level II trauma center has a contract with UCDMC to facilitate transfer of critical pediatric trauma should they happen to be transported to their facility. Every designated trauma center in S-SV region is required to have a transfer agreement with UCDMC for pediatric trauma care.

In addition to the contract for tertiary trauma care with UCDMC, S-SV has contracts with UCDMC and Sutter Memorial Hospital as regional Pediatric Critical Care Centers. Based on the trauma registry data and the strong performance improvement activities of the Trauma Quality Improvement Committee and the work of the Pediatric Advisory Committee we are confident that the highest quality of care is afforded the pediatric population in our Region.

Rehabilitation

The rehabilitation of the trauma patient and continual support of the family members is an important part of trauma system planning. There are no acute rehabilitation centers in the region. However, there are many excellent resources in the surrounding counties. Each trauma center is required to document a plan for integration of rehabilitation into the acute and primary care of the trauma patient, at the earliest stage possible. Hospitals are required to identify a mechanism to initiate rehabilitation services and/or consultation upon admission, including policies regarding coordination of transfers between the facilities. These transfer agreements should provide for periodic feedback of patient progress to the acute care facility to update the healthcare team and ultimately the system trauma registry. Sutter Auburn Faith Hospital has an in-house rehabilitation department.

Critical Care Capability

Critical care capability is determined by meeting the standards set forth in the trauma system plan and detailed in the RFP which includes the assurance of availability of trauma team personnel. The personnel must be consistent with the Level of designation. Each facility applying for trauma center designation must describe the availability of their trauma team members in the applications. Each center must show that it has a trauma service, surgical specialty departments, an emergency department staffed at the appropriate Level, on-call requirements and qualified non-surgical specialists.

Medical Organization and Management

Medical system organization and management for the trauma system will be the same as for the EMS System. An additional Trauma Task Force is established to assist with the development of this plan. This Task Force will continue to play a lead role in the implementation and ongoing process of evaluation of the trauma system. A Pediatric Task Force has been established to review pediatric policies and make recommendations for change. This meeting occurs on a regular basis and includes pediatricians, pediatric intensivists from Sacramento County (Sutter Memorial and UC Davis Medical Center) hospitals that have been designated as Pediatric Critical Care Centers by S-SV.

Quality Assurance and System Evaluation

Each trauma center is required to establish and maintain a Continuous Quality Improvement program specific to trauma. System-wide Continuous Quality Improvement is achieved through the establishment of a Regional Multi-disciplinary Trauma Review Subcommittee. This subcommittee is responsible for establishing criteria or audit filters for review of certain cases that fall outside of established norms for patient care. These meetings are conducted in accordance with '1040 of the Government Code and '1157.7 of the California Evidence code. All members of the committee are required to sign confidentiality statements.

The committee is responsible for establishing the audit criteria for cases to be brought to the committee. Each case has a finding of appropriateness of care rendered and committee members make recommendations to the appropriate committees for changes.

Intercounty Trauma Center Agreements

A contract was executed between the Agency and UCDMC, the designated Level I Trauma Center in Sacramento County, to provide primary trauma coverage to Yolo County. This contract has been in effect since September 13, 1993 and updated on a periodic basis. S-SV Trauma Triage criteria that defines trauma patients is specified in the contract. The S-SV contract with UCDMC for Trauma Care in Yolo County provides for the prehospital medical control by UCDMC for patients meeting the field triage criteria. Patients not initially meeting field triage criteria will be transported to facilities in Yolo County. Criteria for interfacility transfer of patients needing a higher Level of care are in place. UCDMC will act as a tertiary referral center to the facilities in Yolo County who receive injured patients needing a higher Level of care.

S-SV has a contract with UCDMC for Level I pediatric trauma center for the five county region. In addition to the contract for tertiary trauma care with UCDMC, S-SV has contracts with UCDMC and Sutter Memorial Hospital as regional Pediatric Critical Care Centers.

S-SV EMS contracts with Mercy San Juan for Level II trauma care for the few patients that are closer by transport time to the trauma center. Because of the proximity of S-SV to surrounding EMS Agencies and primarily because of patient referral patterns and patient flow patterns S-SV EMS works in collaboration not only with Sacramento County but El Dorado County as well to assure communication and to address system issues as they arise.

Objectives

1. Complete designation of Level III trauma centers for Rideout Memorial Hospital and Tahoe Forest Hospital. Continue to work with Sutter Davis Hospital to designate. Mandate that all acute care hospitals that receive trauma patients from within the five county S-SV EMS region shall submit data to Tri-Analytics registry. Revise and standardize the trauma registry inclusion criteria to allow non-trauma hospitals to input data.
2. Improve trauma care to the rural areas of our region.
3. EMD shall be available to all 9-1-1 calls within the five county region.
4. Utilize EMD protocols to request an Air Ambulance resource at the time of the 9-1-1 call.
5. Incorporate BLS airway training through out the region. To upgrade the basic airway skills of our EMS personnel.
6. CQI - Include more than just death review in TQI committee.
7. Add injury prevention programs.
8. Improve use of central trauma registry.
9. Linkage of trauma databases to prehospital databases.
10. Completion of Collector customization.
11. Encourage a second helicopter landing site at Sutter Roseville Medical Center.
12. Reduce hospital ED closure time.

Implementation Timetable & Milestones

2001

2002

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

25. Update Regional Trauma Plan, Trauma Plan Approval EMSA

X

X

X

26. Designation of Level III trauma centers

X

X

27. Annual review of trauma policies and procedures. Update as needed to meet the trauma system needs.

X

28. Ongoing quarterly TQI Committee Meetings

X

X

X

X

29. Annual trauma data review.

X

Fiscal Impact

Determining system-wide costs for the care of trauma patients is very problematic. Several methods B personal interviews, written surveys of trauma centers, review of statistical data available B were employed to gather data. In a white paper authored by S-SV and a team of trauma professionals, it was determined that system-wide cost data is not readily available or easily identified. (California’s Trauma Care: In Crisis, Appendix # 4) We theorize there are several reasons why this is true:

Trauma care may be intermingled with other emergency medical, intensive care and rehabilitation charges and accounting systems are not established to readily retrieve cost data. To address this issue, S-SV has recently added a requirement to designated trauma centers to gather and report cost data to the Agency.

The costs to the Agency vary depending on the size of the system. S-SV has a trauma registry in place and faces on-going costs of staff, trauma registry annual fees and meeting costs. S-SV submits a financial report annually to trauma centers to account for the expenditures. Each trauma center is assessed an annual fee. The fee rises by six percent each year and must be spent on offsetting trauma expenses to the agency.

Policy and Plan Development

The S-SV region has an inclusive trauma system incorporated in every acute care facility in the region in their trauma system. The Medical Control Committee meets on a monthly basis to review and establish policies and procedures for the transportation and treatment of patients. This committee established a trauma triage criteria (Policy #860, Appendix #1) for transportation of the trauma patient. Included in this policy are authorized catchment areas of 45 minutes by ground transportation to the designated trauma centers.

When an incident occurs within an authorized trauma center catchment area base contact is made with the designated trauma center. Patients with compromised airway or who are pulseless, apneic and asystolic are transported to the nearest hospital. Transfer agreements are in place between the trauma centers and receiving hospitals.

S-SV has contracts with Mercy San Juan Level II trauma center and University of California, Davis Level I, both located in Sacramento County.

All trauma centers are required in their contract to submit trauma registry data. In addition, base hospital contracts require submission of trauma data to ensure a complete record. All hospitals, with the exception of UC Davis utilize Collector. UCDMC submits data to Tri-Analytics for incorporation into the central registry. Data is submitted to Tri-Analytics, Inc. for data completeness and report writing. Reports are generated from Tri-Analytics to the S-SV Agency and each center. All data is submitted to S-SV on disk for analysis and independent querying.

The State requires the following policies listed in the California Code of Regulations Section 100255. The following S-SV EMS policies comply fully with this section.

Each proposal for a Level II trauma center must be accompanied by a non-refundable application fee in the amount of $10,000 to cover the costs associated with the processing of the application proposal review, site evaluation/validation team visits and other designation process expenses. An annual designation fee shall be charged to the designated trauma center to offset the ongoing costs to the Agency for trauma system maintenance, monitoring and evaluation. The fee rises incrementally annually. Level III proposals must be accompanied by a fee of $500. The annual designation fee for a Level III trauma center is $1,500.

S-SV Policy #860 establishes service areas for designated trauma centers. Pediatric patients under the age of 13 with a pediatric trauma score of 8 or less and all children six years of age or less that meet anatomic and/or pediatric criteria are transported directly to UC Davis Medical Center.

Designated trauma center within the S-SV region sign contracts annually. The contracts are presented to the JPA Governing Board of Directors for approval. Transfer agreements between receiving hospitals and trauma centers are required contractually. Transfer guidelines are referenced in S-SV Policy #517 (Appendix #5). The criteria for trauma team activation is based on ACS guidelines. S-SV has established a trauma quality improvement committee which meets quarterly. Sacramento County actively participates in this meeting that functions as a trauma peer review committee.

S-SV Policy #860 states the anatomic, physiologic and mechanism criteria for field transport to trauma centers. This policy also addresses the pediatric patient. EMS personnel are required to attend an accreditation class before being accredited in the S-SV region in order to train them to policies and procedures.

Local Approval

A multi-disciplinary Trauma Task Force originally developed the S-SV Regional Trauma Plan. The Trauma Task Force membership consisted of representatives from the regional hospitals, medical staff, prehospital care providers, non-medical providers, and the Regional Hospital Association. This document represents an update to the original plan and has been written based on input from the EMS/ Provider Community over the last ten years. The changes have largely occurred because of the performance improvements activities associated with the trauma system.

The local approval process of the current revision to the S-SV Regional Trauma Plan shall consist of the following activities. These activities will occur simultaneously. Committees and facilities will be asked to review and comment on the Plan.

Conduct Public Hearing at the JPA Governing Board of Directors Meeting
Submission for review and comments to the S-SV Governing Board of Directors
Submission to all acute care facilities in the Region
Submission to each of the 4 county EMCCs
Submission to the S-SV Medical Advisory Committee
Submission to the Pediatric Committee
Submission to all trauma hospitals in the region
Submission to the S-SV EMS Committee
Submission to EMS Authority
Adoption of the final State approved Plan by S-SV Board of Directors

Data Collection

Optimal care of the trauma patient and organization of a regional trauma system requires accurate data. A trauma registry is defined Aas a database to provide information for analysis and evaluation of the quality of patient care, including epidemiological and demographic characteristics of trauma patients. The registry provides for the collection, storage, and reporting of information about trauma patients, including the facts related to the patient's injury event, severity, care and outcome.

Within the trauma center the trauma registry provides multiple functions. It provides the basis for performance improvement activities, outcome research, resource utilization, injury surveillance, professional and public education and injury prevention. At the regional level the registry provided valuable data about the system as a whole including under and over triage, incidence, costs and outcomes. The data is used to educate the public and public officials about trauma as a public health problem assisting as a basis for legislation and regulatory efforts.

As required by Section 100257 of the California Code of Regulation Title 22, Chapter 7, Trauma Regulations, S-SV EMS has implemented a standardized data collection instrument and implemented a data management system. The prehospital data collection tool utilized is EMScan Data Collection Software. A Special Projects Grant from the EMSA support the implementation of this system in the S-SV EMS region in 1993. The data is collected onto a scantron bubble sheet in which all of the ALS providers complete for each call that they are dispatched to. The scantron sheet is then scanned into a database located at several sites throughout the S-SV EMS region and downloaded to a central server at S-SV EMS on a daily basis. It is then reviewed and used to track trends and given to the QI/Education Coordinator to be used as a tool for the medical control committee to develop and establish policy and protocols for the region. The data that is collected are required data elements that are in Section 100176 of the Paramedic regulations.

In 1995, S-SV EMS contracted with and currently maintains a contract with Tri-Analytics for the trauma registry software “Collector”. Today, four hospitals actively participate in the trauma registry. Participating hospitals include Sutter Roseville Medical Center, Rideout Memorial Hospital, Sutter Davis Hospital, UCDMC submits data to Tri-Analytics. S-SV EMS Policy #860 has been revised adding the requirement that all hospitals that receive trauma patients will submit data to the registry. The hospital trauma registry data set includes the minimal data elements required by Section 257 and additional elements required by S-SV EMS.

Inclusions:

Patients meeting S-SV Prehospital Trauma triage criteria,
Patients meeting ED trauma triage criteria,
Trauma deaths (both inpatient and occurring in the ED),
Trauma patients transferred to or from another acute facility.

Exclusions:

Elderly patients (>65) with isolated hip fractures unless primary event (or E-Code) is trauma related,
Patients with Altered level of Consciousness (ALOC) are excluded unless the primary event is trauma related,
Isolated burns (no associated traumatic injuries),
Drownings, hangings, and electrocutions unless the primary event is trauma related.

Trauma System Evaluation

The evaluation of the trauma system is ongoing and continuous. The Trauma Quality Improvement Committee meets quarterly and is responsible for reviewing trauma care at the trauma centers (morbidity and mortality) as well as the system as a whole. Routine evaluation of trauma registry data is conducted by Tri-Analytics and issues are addressed by the Agency through its Medical Director and Committee structure as identified.

The Medical Control Committee meets monthly and recommends and approves policy revisions for the entire system including trauma, pediatrics, triage, dispatch etc.

Trauma centers must report all closures and diversions and subsequent openings to S-SV Agency using a standard form and faxed to the Agency. Data includes time for closure. QI staff follows up on closures that exceed two hours.

The trauma centers are evaluated on a routine basis. S-SV contracts with the ACS and utilizes the Verification Team Process to validate that the trauma centers meet the facility criteria for trauma center designation outlined in the S-SV Trauma Plan. The trauma centers are inspected every three years. The ACS Verification Team is augmented by an EMS Director contracted with S-SV for this purpose and a hospital administrator to assure all aspects of the trauma program are objectively evaluated. S-SV EMS has the sole authority to designate trauma centers in the region. Designation is determined after the inspection team has submitted a complete report to S-SV and the trauma center. S-SV presents the designation approval to the JPA Governing Board of Directors and a letter of designation is mailed to the trauma center.

A trauma center must submit a written proposal for designation application to S-SV. Written proposals are read and reviewed to determine completeness, ability to meet designation criteria and qualifications of each hospital and its personnel and cost estimate of proposed trauma services. An evaluation team composed of experts from outside the Agency’s region who are experienced in the implementation and operation of trauma services, trauma systems and trauma care are appointed by the Agency. This committee advises the Agency on trauma center designation. A multi disciplinary team includes a trauma surgeon, emergency physician, trauma nurse, neurosurgeon and EMS Administrator. Upon the completion of the review of written proposal and the on-site evaluations the review committee conducts an exit interview to each hospital. The review committee is sequestered and prepares a written report submitting its findings and recommendations to the Agency. Level III trauma centers are reviewed by a committee consisting of the Regional Executive Director, Agency Medical Director, a trauma consultant, Level I and Level II trauma surgeons and others as deemed necessary by the Agency’s Medical Director.

Following receipt of the written report and recommendations of the proposal review committee, the Agency will draft a Trauma Center Designation Agreement based upon the proposal submitted by the hospital that is recommended for designation by the proposal review committee.

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