trauma by lanyuehua


									     Andrew N. Pollak, MD
           Program Director and Head
         Division of Orthopaedic Trauma
    University of Maryland School of Medicine

         Associate Director of Trauma
     R Adams Cowley Shock Trauma Center

                Medical Director
       Baltimore County Fire Department

      Special Deputy United States Marshal

Commissioner – Maryland Health Care Commission
           Maryland vs. Georgia
 Maryland
  –   5.6 million people
  –   12,500 sq miles
  –   $68,000 median income
  –   Density – 5th in US
 Georgia
  –   9.6 million people
  –   60,000 sq miles
  –   $43,000 medial income
  –   Density – 18th in US
                     The Vision
           The Maryland System was created
             by the vision and leadership of
                  Dr. R Adams Cowley

Accidental Death and Disability:
The Neglected
Disease of Modern Society (1966)
                    The Golden Hour
                   The Probability of Survival

                               Survival Is Related To
% Survival

              60               Severity and Duration



                          30           60        90
     The First Trauma Center

Center for the Study of Trauma was opened
by Dr. Cowley at the University of
Maryland Hospital
in 1969.
              Maryland EMS History
  Golden Hour
  Development of
   trauma center network
  Development of
   helicopter network
  Development of EMS

"Politics is not a spectator sport" John F. Kennedy
 R Adams Cowley Shock Trauma
 7500 Admissions per        4200 Surgical Cases
  year                       ALOS 4.65 days
 Approx 40% by air &         – ALOS for isolated femur
  60% by ground                 fracture less than 48
 Primary trauma                hours
  referral center for 1.5    90 total overnight beds
  million people
                              (36 critical care)
 Secondary trauma
  referral center for 6
  million people
      Division of Orthopaedic Trauma
    Research – Education – Clinical Care
 7 Full time faculty members
 10 Orthopaedic residents
 4 Orthopaedic trauma fellows
     – Expanding to 5
   3000 orthopaedic trauma cases annually
   400 pelvis and acetabulum cases annually
   $500,000 per year research funding
   20-30 Academic peer reviewed publications
    per year
   Division of Orthopaedic Trauma
         Residency Programs
 University of Maryland    Walter Reed Army
 Columbia University        Medical Center
 New York University –     Bethesda – National
  Hospital for Joint         Naval Medical Center
  Diseases                  Tripler Army Medical
 Lenox Hill Hospital        Center
 Union Memorial            Johns Hopkins
  Hospital                   University

          Educational Mission
                            Continuum of Care
                            Emergency Incident
                             Citizen Access “911”
        Dispatch                                              Dispatch Units
Information Pre-arrival Information                        Fire BLS ALS Specialty Uni

  Medical Consultation        Patient Assessment
                              Ambulance Medic Helicopter

      Hospital Emergency Department or Specialty Center

         Rehabilitation                      Return to Society
            Maryland EMS System
3           32                     2                                     159
H                    A             H       A

                                               51                   23
                 Baltimore City                                     H          7
                 A                                  A
                                 H                                             H
                         H     A
                          H    H       A
                         A H H
                 H                     H                        A
                         H     H                        H H
                     H                                    H
                         H                                160            13

        Areawide Trauma Centers
    H   Specialty Referral Centers
    H   Hospitals
        Central Alarms
        EMSTel Telephone Network
        Medical Command Consultation Centers
              PARC     Burn

Trauma Level I Maryland’s Eye       Specialty
Centers         Trauma              Referral
                System      Hand Centers
    Level II
                           Head and Spine
    Level III
              H            Pediatric
                   H    Perinatal
        Local Emergency Departments
                Maryland EMS
• System highlights
  – 5 regions
  – 24 jurisdictions (23 counties and the city of
    Baltimore) plus statewide EMS agencies
  – 31 commercial ambulance services
  – Statewide EMS Advisory Council (SEMSAC)
  – EMS Board appointed by Governor
  – EMS and trauma funding through $13.50
    surcharge on vehicle registration
  – Majority of EMS providers are volunteer with a
    strong state association (MSFA)
              Maryland EMS
• System highlights
  – Statewide EMS communications system operated
    by MIEMSS
  – Statewide protocols for EMS providers
  – Statewide data system
  – Uniform QI and medical oversight requirements
  – ALS available in all jurisdictions
  – MSP Med-Evac program with 8 bases across the
    state transporting more the 3000 patients/year
  – Trauma, EMSC and EMS systems are integrated
              Maryland EMS
• System highlights
  – R A Cowley Shock Trauma Center is a statewide
    trauma resource by statute
  – 8 additional adult trauma centers and 2 pediatric
    trauma centers
  – MFRI provides EMT-B training and EMS CME
  – ALS training provided by jurisdictions,
    community colleges and UMBC (up to masters
           Trauma Centers
• Primary Adult
  – R Adams Cowley Shock Trauma Center,
    University of Maryland Medical Center
• Areawide
  – Johns Hopkins Bayview Medical Center
  – Memorial Hospital and Medical Center of
  – Peninsula Regional Medical Center, Salisbury
  – Prince George’s Hospital Center, Cheverly
  – Sinai Hospital of Baltimore
  – Suburban Hospital, Bethesda
  – Washington County Hospital Association, Hagerstown
• Pediatric
  – Johns Hopkins Children’s Center :Pediatric Trauma
  – Children’s National Medical Center: Em. Trauma Ser.
    Fire Department
911 Center and Dispatch

                                                        4   Gathers Data

                            Randomization                       Data
                               Request                       Coordinator
                        1    and Protocol                       Paged

                                                                                   Data Submitted
                                                                                    to MIEMSS

                       Patient Transported
                                                                    Gathers Data

                        MAIS Runsheet
  Maryland EMS and Trauma
     Sources of Funding
• EMS/Fire/911
• Trauma Centers – Hospitals
• Trauma Physicians
  Funding of Trauma Services
• Emergency Medical Services Operating
  Fund (EMSOF)
  – Helicopter Services
  – MSFA low-interest loan fund for fire/EMS
    apparatus for volunteer organizations
  – STC Stand-by costs/equipment costs unique
    to role as PARC
  – MFRI Support
  Funding of Trauma Center Costs
• Hospitals in Maryland are rate regulated
  – DRG Waiver since mid-80’s
  – All-payer system
  – Regulated by HSCRC
• Rates established based on allowed costs and
  allowed margin
  – Traditional allowed costs include costs associated
    with provision of services to uninsured patients
• System protects hospitals with regard to
  exposure of costs of uninsured patient care
   Maryland Trauma Physician
  Services Fund – Context - 2002
• Inadequate specialist coverage of trauma
  on-call panels was becoming increasingly
• Multiple factors contributed to making the
  trauma on-call environment unattractive to
• Some of them relate to financial issues
• Financial issues themselves are
  – Expense related issues
    • Perceived increase in liability exposure
    • Opportunity cost of lost time in elective practice
  – Income related issues
    • RBRVS methodology invalidated by creation of
      trauma system!
    • Burden of care of uninsured and Medicaid (under-
      insured) populations
    Maryland Trauma System
• One model to address one component of
  the problem of physician coverage at State
  designated trauma centers
  – Successful
  – Links physician care at trauma centers to
    EMS/Fire/Rescue services
  – Recognizes trauma care as an essential
    public service distinct from remainder of
    traditional health care
   Trauma Physician Services
• Richly funded statewide trauma EMS
  system ultimately dependent on quality of
  physician services provided at trauma
• 2001-2002 Crisis in coverage at
  Hagerstown led to recognition of need to
  fund trauma physician services to tip
  balance back toward facilitation of
  participation in on-call panels
    Maryland Trauma Physician
          Services Fund
• Funded by $2.50 per year surcharge to
  state vehicle registration fee
• Administered by Maryland Health Care
• Provides payment for physician services
  for trauma patients in trauma registry at
  state designated trauma centers at
  Medicare rates
      Maryland Trauma Physician
            Services Fund
• On-call payments
• Medicare rates for
   – Uninsured
   – Medicaid
• Broad spectrum of
• Grants to hospitals for
  equipment costs
• Grants to out-of-state
  hospitals that provide
  trauma specialty care to
  Maryland residents
     Trauma Physician Payment
•   PIP - $2500
•   Commercial – variable
•   PPO – Variable
•   HMO – 140% RBRVS
•   Work Comp – 144% RBRVS
•   Uninsured/Medicaid – 100% RBRVS
        Ongoing Challenges
• 100% of Medicare is better than nothing
  but not adequate for complex trauma
• Maryland Trauma Physician Services
  Fund being raided by hospitals
• Payment to hospitals to reimburse for on-
  call stipends does not guarantee that on-
  call physicians will actually care for
• Trauma care must be regarded as an
  essential public service like police and fire
• An integrated model for 911/EMS/Trauma
  allows for focus on quality and reliability of
• All components of delivery must be
  adequately funded to achieve excellence
"Americans do the right thing after they've tried everything else" Winston Churchill

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