Southern N District MINUTES EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM REGIONAL TRAUMAADVISORY BOARD FEBRUARY24.2016 - 2:30 P.M. MEMBERSPRESENT SeanDort, MD, St.Rose Siena Hospital, Chair DaleCarrison, DO, University Medical Center Kim Dokken, RN, St. Rose SienaHospital John Fildes, MD, University Medical Center Abby Hudema, RN, University Medical Center Chris Fisher, MD, SunriseHospital Alma Angeles, RN, Sunrise Hospital Senator Shirley Breeden, Public Representative SajitPullarkat, Centennial Hills Hospital MargaretRussitano, RN, Sunrise Hospital Eric Dievendorf, Paramedic, AMR FrankSimone, ParamedicNorth LasVegas Fireept. Erin Breen,Transportation Research Center, UNLV Danita Cohen, RN, University Medical Center Dineen McSwain, RN, University Medical Center SNHD STAFFPRESENT JohnHammond,EMSTSManager AnnetteBradley,Esquire ChristianYoung,MD,EMSTSMedicalDirector HeatherAnderson-Fintak, Esquire Laura Palmer, EMSTS Supervisor Mike Bernstein, SNHD-OCDPHP LeiZhang,PublicHealth InformaticsScientist RaePettie,RecordingSecretary Joseph P. Iser, MD, ChiefHealth Officer(via teleconference) PUBLICATTENDANCE Stacy Johnson, RN, MountainViewHospital Josh Hedden, MountainViewHospital Maya Holmes, CulinaryUnion James Sullivan, Culinary Union Pam Udall, UNLV School ofMedicine ChrisMowan,COO,MountainViewHospital DanMusgrove, Valley Health System Julia Sbragia,University Medical Center BibiMartin,University Medical Center CaleshaJohnson, University Medical Center Kimberly Cerasoti, UniversityMedical Center JenniferRenner, RN, HCA Healthcare BillBullard, Abaris Group Amy Leong, Culinary Union Daniel Llamas, HCA Healthcare NancyNowell, RN,Centennial Hills Hospital ChrisStachyra,Mercy Air ElizabethSnavely, University MedicalCenter Catherine Jones, ValleyHealth System DebraFox,University MedicalCenter Alex Ortiz, MD, University Medical Center Carissa Rey, University Medical Center AlistairChapman, MD, University MedicalCenter EricaNansen, University MedicalCenter MarcJeser, DO, Centennial Hills Hospital Kelly Stout, Esquire, Bailey Kennedy George Ross, HCA Healthcare Adam Rudd, CEO, Southern Hills Hospital James Lovett, MD, Centennial Hills Hospital Melody Talbott, University Medical Center ToddSklamberg, CEO, SunriseHospital William Osby, HCA Healthcare Steve Burton, Paramedic, LasVegas Fire & Rescue Joshua Dickey, Esq., BaileyKennedy Vick Gill, UniversityMedical Center AndrewChung, University MedicalCenter Ellin Mardirosian Todd Lightower, Sunrise Hospital Doug Dobyne Dan Hart Mason Van Houweling, CEO, University Medical Center RegionalTraumaAdvisory BoardMeetingMinutes Page2of15 CALLTO ORDER- NOTICE OFPOSTING The Regional Trauma Advisory Board (RTAB) convened in the Red Rock Trail Conference Room at the Southern Nevada Health District, located at 280 S.Decatur Boulevard, on February 24, 2016. Chairman Dort called the meetingto order at 2:30 p.m. and the Affidavit ofPosting was noted inaccordance withthe Nevada Open MeetingLaw. Chairman Dort noted that aquorum was present. I. PUBLIC COMMENT Members ofthe public are allowed to speak on Action items after the Board's discussion and prior to their vote. Each speaker will be given five (5) minutes to address the Board on the pending topic. No person may yield his or hertime to another person. Inthose situations where largegroupsofpeopledesiretoaddresstheBoardonthesamematter,theChairmayrequestthat those groups select only one ortwo speakers fromthe group to address the Board on behalfofthe group. Oncetheaction item isclosed,noadditionalpubliccomment will beaccepted. Maya Holmes addressed the Board on behalfofthe Culinary Workers Union (CWU), Local 226, related to the three applications submitted for initial designation as a Level III center for the treatment oftrauma. She stated that the Culinary Health Fund sponsored by their union and Las Vegas area employers provides health insurance coverage for over 143,000 Nevadans, which consists ofthe members and their dependents. She noted that through the health fund they are oneofthe largesthealthcareconsumers inthestate. Theyare deeplycommittedto upholdingthe principles laid out in the 2015 Southern Nevada Trauma System Plan that rightly prioritizes the welfare ofthe injuredpatients,qualityoutcomes,costeffectiveness, andthe economic viabilityof the Clark County traumasystem. Their members, their families and the entire community rely on it. Ms. Holmesstatedthe CWU is extremelyconcernedabout the impacton the existing systemif we expandthe number ofLevel IIItraumacenters. TheCWU does not believe there isany need for expansion at this time. She added, the trauma facilities at University Medical Center (UMC) are a tremendousand vital resource in our community,unlike other hospitals in the Las Vegas valley. All ofUMC's resources remain hereto provide residents with affordable and accessible healthcare. Additionally, damaging UMC's financial health will place a fiscal burden on the countyand itstaxpayers. Ms. Holmes noted she had a letter to enter into public record that details the CWU's concerns (Attachment L). In the letter, the CWU states that expansion ofthe trauma system should be based on actual need, and should not destabilize or degrade the existing system, duplicate services, or unnecessarily increase medical costs. They note that none of the applicationsfor LevelIIIdesignationdemonstrate thatthecurrentsystemisactuallyat,orover,capacity. Rather, their proposals focus on population and trauma volume growth. She stated that two of the proposalsexpect trauma patientswill be redirectedfrom existing centers, primarily UMC,who hasthecapacity, volume, skillsandexpertise totreatthosepatients. Twoapplications project a 7%populationgrowthbasedonjust threeyearsofdata;an 11.9%growthratefrom2012to2013; and a 2.1% growthrate from2013to 2014,foran averageofgrowth rate of7%. However,the compound annual growth rate of total traumatransports from 2010 to 2015 is actually down 4.86%atthesystem's onlyLevelIIItraumacenter. A2.15%and2.24%growthratein2014and 2015 leads the CWUto question a 7% growth rate inthe future. The CWU is also concerned that splittingthe trauma patient pool could worsen outcomes for patients because it reduces the experience any one center has. It is critical to ensure there is sufficient volume at trauma centers to develop and maintain the skills of trauma teams and delivery quality outcomes. Ms. Holmes noted that a recent study found that for every 500 additional traumacasesseenat a trauma center, the mortality rate drops by 7%. Weare also extremely concerned thatthedesignation ofnew trauma centers willlead todramatically higher medical costs forpatients andtheirfamilies. Level III traumacenters typically treatpatients with injuriesthatcould likely behandled bywell equippedand well staffed hospital emergency rooms; RegionalTraumaAdvisoryBoardMeetingMinutes Page3of15 however, they can also charge a high trauma activation fee, which dramatically drives upthe cost ofcare for patients. There has been a rapid growth oftrauma centers, especially Level IIItrauma centers in places like Florida. In a 2014 investigation, the Tampa Bay Times found thousands of cases in which patients with minor injuries were charged a trauma response fee. The fee was often more than all oftheir other medical charges combined. Many spent less than a day in the hospital. She added that one large systemthat operates inNevada charged trauma patients over $124,000 on average, roughly $40,000 morethan patients were charged at other trauma centers in the state. In 2014, Florida Blue, its largest private insurance company, paid an average of $117,150 per trauma patient in that system;nearly double the amount that Florida Blue paid to otherstatetraumacenters. Ms. Holmes concluded by reiterating that the CWU believes an unnecessary expansion ofthe trauma system will underminethe existingtrauma resources and result inhighercosts to patients. Pam Udall addressed the Board on behalfofthe UNLV School of Medicine (UNSOM). She stated she also had a letter to enter into public record (Attachment M). Ms. Udall also stated UNSOM is concerned about expanding the trauma system beyond the UMC region. Right now UNSOM isreallydedicated to improvingthephysicianshortage inNevada. Their goal istogrow medical students, residents, ER physicians, orthopedic physicians and fellowships. UNSOM feels that by expanding the trauma system they will dilute and duplicate the resources that are already being done at UMC, which could ultimately Jeopardize their residency programs. UNSOM's goal is to grow residency and fellowship programs so they can produce more physicians inthisarea, notjeopardize thecurrentresidencyprogram sothey can'ttrain physicians here. It's very important that our residents have experience. The orthopedic residents have a wide range ofexperience from Level I, IIand IIItrauma patients. It's importantto havea huge caseload because in order to get certified to teach residents you need to show that you have a certain number ofpatients coming in. We need a wide mix ofpatients to have a wide array of training experiences. UNSOM's goal istotrainvery highlyskilled physiciansforthefuture. Ms.Udallconcludedbystatingthe Boardmustensureitsdecisionforexpansionwill not impact whatUMC,a LevelItraumacenter, iscurrentlyofferinginitsmissionto improvetheshatageso we can produce more physicians, not less. II. CONSENTAGENDA Chairman Dort stated the Consent Agenda consisted ofmatters to be considered by the RTAB that can be enacted by one motion. Any item may be discussed separately per Board member request. AnyexceptionstotheConsentAgendamustbestatedpriortoapproval. Approve Minutes/RegionalTraumaAdvisorv BoardMeeting: 10/21/15 Chairman Dortaskedforapproval oftheminutes from theOctober21,2015meeting. Amotion was made bv Dr. Fildes. seconded bv Erin Breen. and passed imanimouslv to approve the minutesas written. in. REPORT/DISCUSSION/POSSIBLE ACTION A. TraumaSvstem Authorization Procedure Presentation John Hammond provided the Boardwith a presentation(AttachmentA) on the trauma center authorization process. Heexplained thatthe RTAB holdsquarterlymeetingsto reviewdata and assess the status ofthe traumasystemon an ongoing basis. Data is obtainedfrom the trauma field triage criteria, the Trauma Medical Audit Committee (TMAC), and the trauma registry, asavailable. If,during thattime, aneed foradditional traumacenters, orchanges to existing trauma centers isidentified, theDistrict Board ofHealth shall publish aRequest for Proposal (RFP)fortheaddition ofacenterforthetreatmentoftraumaorpediatric centerfor thetreatmentoftrauma, orforachange inlevel ofauthorization foranexistingcenterforthe treatment oftraumaorpediatric center forthetreatment oftrauma. Alternatively, ahospital RegionalTraumaAdvisoryBoardMeetingMinutes Page4of15 may submit an application for the same. Staffreviews all applications based upon criteria outlined in the Trauma Regulations. A recommendation to either support or deny the application isthenmadeto the District Board of Health. Ifthe application isapproved and authorizationis granted,the recommendation isforwardedto the Nevada DivisionofPublic and Behavioral Health (DPBH where they will conduct a designation process as outlined in theNevada Administrative Code(NAG). Duringthattime the American CollegeofSurgeons (ACS) will initiate the verification process and let the DPBH know that the verification processeshavebeencompleted. Uponsuccessful completionofACSverification,the DPBH will issue written notification ofthat designation, including supplemental licensure for the facilitytoengage intrauma careservices. B. Trauma Svstem Data Collection Report Presentation Mr. Hammond provided the Board with a detailed presentation (Attachment B) on the trauma system data collection process. He beganwith an overview ofthe legislative authority, NRS 450B.764, which mandates the Health Division to develop a standardized system for the collection of information concerning the treatment oftrauma and carry out a system for the management ofthat information. The system must provide for the recording of information concerningtreatment received before and after admission to a hospital. Per state law the data must be submittedby both trauma and non-trauma centers. Mr. Hammond reported that inthe absence ofa functioning trauma registry, a subset oftrauma registry data is provided to the Office ofEMS & Trauma System (GEMSTS) by all trauma centers in Southern Nevada. All data validation is done manually, which means that the dataset submitted to the GEMSTS has to be matched to the EMS call data, an extremely time consuming process. The trauma centers submit data for trauma patients electronically on a monthly basis via a HIPAA compliantserver. The GEMSTS then filtersthrough monthly TransferofCare (TGC) datafor the exact number of incidents in the 9-1-1 system involving a traumatic patient. The TGC data is compared with data from each traumacenter in orderto verify both the initial location of the emergency, as well as the trauma center designation. The current process for data collection and analysis is intended to provide an overviewoflocal traumaactivities. Gnce the trauma registry is operational the data will provide information about all trauma patients as defined by the ACS. This includes patients who have sustained a traumatic injury but were not seen ortreated ata traumacenter. Abby Hudema inquired whether there is any recourse for applicants who are denied designation by the Board of Health. Mr. Hammond replied that per Section 300 of the Trauma Regulations, the hospitalcan seek remedy through the District Court. C. TraumaSvstem GuestionsPresentation Mr. Hammond provided a PowerPointpresentation (Attachment C) that includedquestions emailedto himaboutthestatusofthetraumasystem. Johnexplainedthe ACS'sNeeds Based Assessment of Trauma Systems (NBATS) Tool grades the median transport time in the trauma service area. He reportedthataccordingto the2015 data, the mediantransporttimeto the trauma center in the trauma service area for all steps was 16 minutes, 42 seconds. Rush hour and other factors relatedto roadconditionsare taken into considerationby EMS crews and applied along with protocol guidelines in determining trauma destination. Step 3 and 4 patientsdonotgenerallyrequireexpeditedtransportation toahospital. In response to the question related to trauma declination, Mr. Hammond stated that trauma centersmay use trauma bypass as needed; however, UMC does not decline transfers. He sent emailsouttoSunriseandSt.RoseSienatoaskiftheydeclinetransfers, andifso,theyshould send a declination report tothe GEMSTS so a determination can be made as to whether there is an excess trauma bed capacity. Ms. Dokken stated that St. Rose Siena does not decline transfersas longastheycanmeetthelevelofcare.Mr.Hammondconcludedthepresentation by stating that the payer mix data is irregularly presented at the TMAC. The TMAC is a RegionalTraumaAdvisoryBoardMeetingMinutes Page5of15 closedmeetingsothosedataarenotpublicallyavailablefromtheOEMSTS.Ms.Breenasked ifthere was any indicationthat patientsare not reachinga current trauma center intimeto be adequatelytreated. Mr. Hammondrespondedthat he could find no evidenceofthat in his research. Dr. Fisher asked what measures are used to arrive at what is considered an unacceptable transport time. What is considered the tipping point to where we realize we need another Level IIItraumacenter? Mr. Hammond responded that it's multifactorial; we have to look at outcomes from the hospital itself, such as ifthere's an increase in mortality, or in business to the OR, or an increase in admissions for mechanism only patients. Additionally, the ACS specifies median transport time in the trauma service area, which in this regard is Clark County, Nevada. Rural areas can have very low volume, but high transport times. If you couple that with the applicantsenteringthe system as a Level IIItraumacenter, transport time isnot clinically significantfor those stable patients as they travel roadway speeds, obeying all traffic laws to get to the trauma center. He used the example ofIndian Springs, which is 30 miles away, or Cactus Springs, which is45 miles away. He stated you can't safely make that transport time in 30 minutes. But those individuals are stable, mechanism only, or Step 4 patients. Soyou have toweigh the clinical factors along with the distance. Dr. Fildes noted that the ACS has developed, ina multiple stakeholder manner, a needs based assessmenttool. Itallowsyou to look at the nuances through a seriesoftechniques developed through their advisory committee. He pointed out that not every system can be viewed the same; some are heavily urban, some are mixed urban/rural, and the needs ofthe people have to be considered first. It has to be done by looking at the local data to find out where need existsand to see ifyou can match the resources to the patientneed. He added that most ofthe regulations setthe floor, but not the ceilingforthat activity. D. TraumaSvstem Presentation Dr. Fildes provided the Board with a presentation (Attachment D) that included both historic and current information to begin the discussion. He began by stating that the Southern Nevada Trauma System is working well. There are no incidents or reports where patients or EMS couldn't access trauma center care in a timely manner. When the local, regional and national benchmarksare examined by the TMAC and RTAB we fall well within the high performing range. He expressed concern that doubling the number oftrauma centers at one time isunwise,unsafe,anddangerous-especiallytothenewapplicants, becausetheyaremost likelyto fail. He statedthat it's notwiseto growa traumasystemby dismantling partsand pieces ofthe Level I trauma center to create an over-supply ofLevel III trauma centers. A Level I trauma center is an essential asset; it trains and produces nurses, paramedics, technicians, doctors, and provides research, outreach and other critical features. A needs- basedassessment and populationstudiesmust identifyaneed for new Level IIItrauma centers based on new growth, not by cannibalizing currentlyoperating systems that are operating well. The same applies to all existingcenters~the Level II and Level IIItrauma centers also should not be cannibalizedto createnewcenters. Dr. Fildes showed a manuscript from the CDC that was published in the January 2012 MMWR (Morbidity and Mortality Weekly Report). It came from an expert field triage criteria committee. It operationalizes the injury pyramid put out by the World Health Organization(WHO). Heexplainedtherearefourtypesoftraumapatients. Step 1patientsare patientswho havephysiologicderangements, i.e.altered mental status, low bloodpressure, tachycardia, hypoxia—physiologic evidencethattheinjuryisendangeringtheir life. Step 2 patients are patients with anatomic problems such as open pelvicfractures or open skullfractures-anatomic evidencethatthis patientisinfact,at riskoflifeor limb. RegionalTraumaAdvisoryBoardMeetingMinutes Page6of15 Step3 patientsare patientswho are awake,alert and stable, who don't qualify for Step 1or Step2, butwho have sufferedasignificantmechanism likea fall,or perhaps amoderate speed carcrash. Step4 patients are special populations likechildren,the elderly or pregnant womenwho may beatextra riskwhen lowenergy injuriesaresustained. Dr. Fildes explained that the manuscript describes why the patients are stratified inthis way, and how they are distributed to acute care facilities. He stated that he was serving as the National Chairman ofTrauma as the medical director for trauma programs for the ACS, and he helped the CDC facilitate this expert panel, and was imminently involved in the trauma system planningdocuments. The next slide was from the American Trauma Society, which demonstrates that patients should be seen within the Golden Hour. The first thirty minutes of the Golden Hour is prehospital; the second thirty minutes is in hospital. Injuries are stratified and reported to the EMS System, which then triages them inthe field and determines whether they goto a regular emergency department where they're likely to be treated and discharged. Ifthey're found with significant injuries they would be transferred up. Alternatively, if EMS finds that they have life-threatening injuries they'd be sent to a trauma center and would go through the spectrum of treatments that route them back through rehab and return to home, work and family. He noted that all hospitals treat injured patients, but not all hospitals are trauma centers inamodemtrauma system. Dr. Fildes stated that Step 1(physiologic) and Step 2 (anatomic abnormalities) criteria drive patients to Level I or Level II trauma centers for their care. In our system, patients that are Step 3 or Step 4 could be seen either in a Level I, II or III trauma center. Step 4 patients can clearly be seen in any hospital emergency department. The work ofa Level I or II trauma center is simply stated as: The careof seriously injuredpatients with physiologicor anatomic abnormalities,andanyandallothers. Butthe LevelIisalsotasked with performingresearch, prevention activities, teaching and training. And it requires a larger number of complex patients that are concentrated into a clinical environmentwhere these tasks can take place. LevelIItraumacentersdeliverthesameclinicalcareandtheydotreattheseseriouslyinjured patientswith physiologicand anatomic abnormalities, as well as all others. But the work ofa Level III traumacenter is different. Level III traumacenters care for stable patients—they don't qualify for Step 1 or Step 2 patients. They don't have physiologic or anatomicabnormalities,butthey've beeninvolvedin mechanismsofinjurywherethey have special considerations that are concerning. These patients are fully awake, alert and oriented; they have normal blood pressure, pulse and saturation, and they're stable. When these patients are transported, they're transported without lights and sirens. They travel at the posted street speeds, and the transport time is not as critical because the patients are not critical. Inmanysystemsthesearepatientstreatedatemergencydepartments. Dr.Fildesstatedthat St.RoseSienahasfunctioned verywellas a peripheralLevelIIItrauma center. They see roughly see abouttwo patients a day, about 60 a month. Theyaverage between 50-70 patients a month. 85% of the patients they see are either treated and discharged, or transferred to a higherlevel of care. Less than four patients per year are admitted directlyto an operating room oran ICU. Andabout 15%, or about 10patients per month, are admitted. That's the published data. They now have three applications from hospitals who want to engage inthis levelofcare. Dr.FildesgavetheBoardsomehistoryastowhatisuniqueaboutthe LevelItraumacenterat UMC. In 1986,UMCwasthe SouthernNevadaMemorialHospital and there wasone bedin the emergencydepartmentthat was dedicated to trauma. At that time, the population was beginningto surgeand itwas clearthat the needfor the communitywas not met. An effort was createdto designate and create some traumacenters around 1987 or 1989. He believesat that time that Sunrise and Valley came in as Level III trauma centers, but because of the RegionalTraumaAdvisoryBoardMeetingMinutes Page7of15 difficultyoftreatingthepatientsandthepoorpayermix,bothdroppedout. Atthattime,with thesurge inpopulation andtheabsenceofpartnersinthe trauma system,the SouthernNevada Memorial Hospital made a decision to build a large, high capacity, stand-alone trauma center to meet the community need. The trauma center was opened in 1992, and it became designated as a Level I, and ultimately as a pediatric Level II. The Level Itrauma centerwas built bythe demand ofthe communityforthe needsofthe community. T was purposely built for high volume and high acuity. A stand-alone center means it stands alone on our property and is not part ofthe emergency department. It's not part ofthe main hospital, and within its four walls it is completely self-contained. It's about 20,000 plus square feet; a little bigger than four basketball courts. It is a purpose built facility that has 11 resuscitation beds, three dedicated operating rooms, 14-bedclosed ICU, its own blood bank, pharmacy and lab. UMC has itsowm radiology assets, includingCT-scanningand angiography. That's a24-hour aday, on-sitestaffinsurgery, emergency medicine, anesthesia, residentteams and nursing teams. When UMC entered into a partnership with the University of Nevada School of Medicine (UNSOM) it became the only training site for residents in the state. This June they will graduate the 100*^ general surgeon trained in Nevada. They're currently graduating emergencymedicine residents, plastic surgery residents, ENTs, and this yearfor the first time, they will start an orthopedic residency program. The orthopedic residency was approved by ACGME (Accreditation Council for Graduate Medical Education, a private, non-profit organization that reviews andaccreditsgraduatemedical education (residency and fellowship) programs, and the institutions that sponsor them in the United States) based on historic numbers oforthopedic cases flowing through the trauma center. By July 2017 UNLV will become UMC's primary affiliate. Dr. Fildes noted UNSOM is a worthwhile and worthy community asset thatmust besupported. Headdedthat UMCcurrently hasa residentrotating in trauma surgery that comes from an HCA hospital in Florida. He doesn't see why we couldn'tdothe same from across town. UMC has also developed a partnership with the U.S. Air Force and Nellis Air Force Base. Theyare intendingtoembed moreactivedutypersonnel intopediatrics andobstetrics. The SMART(SustainmentofMedicaland Resuscitative Training) programis a programfor sustaining battlefield readiness and battlefield medical skills in between active and duty deployments. UMCcurrentlyhassurgeonsherefromthreestatesthatarerotating. Dr.Fildes stated the reason they chose UMC is because it's uniquely designed as a high volume, high acuity center where in a short number of weeks a surgeon or an emergency medicine physician, an anesthesiologist, a nursing team, or a respiratory therapy team could see the necessarynumberofcomplexcasesformilitary sustainment. UMC teaches an advanced trauma life support course and a disaster medical course to over 700 providers. They've published over 100articlesand bookchapters. They broughtover $11 millioninresearch revenue tothevalley, thereby creatingjobs. Andthefaculty isoften asked to lectureandparticipate innationaland international levelconferences. Dr. Fildes presented statistics from 2000 through 2015 that represents UMC's trauma admissions. InAugust2005,twonewtraumacenterswereaddedinthevalley. Referring to the graph, he stated that from that time on UMC began losing volume. The population estimatesdiscussedinthepublichearings citeda 7%growth. UMCwastoldeverythingwas okay;everythingwould go backtonormal inayear. Thegraphdepicted thataftertenyears, UMC's trauma admissions are still not back to normal. He explained the increase in admissions in the lastthreeyearscameas a result of liberalizing Step 4 and transporting minimally injured special population patients. Theincrease isnotcomprised ofpatients that arecritically injured~the kindrequiredfortrainingandforresearch,which isUMC's mission. They are the kind of patientsthat can be treated in general hospitals. Dr.Fildes notedthe system shouldactually lookat thesepatients as a potential sourceof over-triage, leading to excessivespendingofmedicalfinancial resources. RegionalTraumaAdvisoryBoardMeetingMinutes Page8of15 Dr. Fildes stated that the notionthat we coulddouble the number oftrauma centers bytaking patientsaway from UMC becausethe populationestimate isthat we'll regain them sometimes in the future is a ridiculous discussion. He contacted the county demographer to ask for accurate numbers with regard to population, and learned that the population isn'tsoaring. Dr. Fildes stated that UMC's mission to train residents is based upon them earning a specified numberofindexed operativecases and clinical experiences. Ifthey don't, then the residencies will be taken away from them. Heexpressed concern that there isnot enough data to make an informed decision atthis time. Dr. Fildes pointed out an article from Modem Healthcare (September2015) that outlines why the number oftrauma centers is rising in the U.S. He pointed out it's a financial argument. There are more insured individuals,and providingtrauma care allows charging higher facility fees and trauma activation fees, and provides a halo effect that stimulates other hospital services like blood bank, physical therapy, radiology, and the like. The Presidentand CEO of The Abaris Group, a healthcare consulting firm, re-published in this month's newsletter that these hospitals are learningthat there's nota lotofconstraints asto whether they can go after trauma or not. The consulting group stated that at some point we're going to have too many traumacenters, and that doesn't helpanybody. Dr. Fildes stated that basing their analyses on zip codes is no more than an exercise in postal efficacy; we're not delivering mail, we're delivering patients. The trauma system should be designed around municipal boundaries; it should be designed around police and fire jurisdictions. Additionally, itshouldbe looking at physicalboundarieslikerailroad rightsof way, highwaycrossings,and the like. Itshould lookat the needs of the communityand the people who live in the community. It should look at the number of cases generated in the community. It should look at balancing all the resources so that everyone is successful in caring for the community, and it should do so in a cost efficient manner than doesn't have over-triage as afinancial burdentothepayers. Dr. Fildes referred the Board to Dr. Mark Faul's article from the MMWR that was written simultaneously with the creation ofthe trauma field triage criteria bythe CDC. He stated Dr. Faul is a well-known researcher, and is listed as the third author on the article. He stated that when public policy is formedat the federal levelthey look at two things; lives and dollars. They want to save lives, and they want to spend dollars wisely. The last creation of the traumafieldtriagecriteriawerebelieved togettherightpatient, therightcare,therightplace attherighttime,andtosavelivesandsustain thelife-savingeffectsthathavebeenrealizedby organized trauma systems over the last three decades. At the same time, those trauma field triage criteria were believed to be tightened up enough to reduce over-triage and reduce healthcare spending forunnecessarytraumacentervisits. Dr. Fildesconcluded hispresentation byreiteratingthattheSouthernNevadatrauma system is working well. There are many reasons why doubling the number oftrauma centers at one time is unwiseand dangerous. Everytraumasystemhas an academic Level Itraumacenter thatis anessential asset thatactually brings more than ittakes. You cannot build a really effectivetraumasystembydismantlingexistingLevelI, IIand IIItraumacenterstocreatean oversupplyof Level IIItrauma centers. And we've been directed by the CDC,the federal government,andtheACStoconductneedsbasedassessmentsand populationbasedstudiesto identify needsand locations fornewcenters. Heremarked that it's beenadequately doneto date. Dr. Fildes stated the applicants have done a good job in bringing forth their desire to participate. Inhis opinion there needsto bea needsbasedassessment taskforce created,with oversightbythe Health District. Hebelieves thestakeholder groupforthattaskforce should be broadto includebothcurrentandfutureapplicants. The metricsand measureshaveto be determined and agreed upon, and defined as to not if, but when, new trauma centers will be needed. Also,whentheycanenterandhowweshouldcarrythisforward. Headdedtherehas beena lotof discussion aboutwhatthemaplooks likeandwherethe peoplelive. Hestated RegionalTraumaAdvisoryBoardMeetingMinutes Page9of15 that they can talk all they want aboutMt.Charleston or Indian Springs; however, lookingata picture ofClark County taken byNASA,99% ofthe patients who are going to needtransport and treatmentare where the lights are. Dr. Fildes referred the Board to the ACS' NBATS (Needs Based Assessment of Trauma Systems) tool and noted that it was created at a multiple stakeholder high level meeting. The tool looks at six discreet areas: population trends, median transport time, lead agency system and community support; the volume and distribution ofseriously injured patients; the role of the Level 1academic trauma center as an essential asset; and the number ofseverely injured patients seen in trauma centers that are already in the trauma system. The stakeholders consisted ofthe Vice President ofTrauma Services for HCA, the Nevada State EMS Office, and the Florida Department ofHealth, as well as the ACS and a handful offederal agencies. He believes that the work they put forward should be exercised here and that we should look at their own data to try to determine if, where, and when new centers should come on board. He suggested SNHD create a needs based taskforce utilizing the NBATS tool and the ACS trauma system document for guidance. The tool must assess the applicant's preparedness as well as community factors, and also assess the impactofnew centers one at a time so that the new applicants are successful, and the existing trauma centers who have already made their commitmentare protected. Dr. Fildes apprised the Board that he will make two motions as an administrative responsibility to deny approvalof authorization for the three applicants,but simultaneously advocateforthecreationofaneedsbasedassessmenttaskforceto includeallthreeapplicants, inadditiontowidercommunity stakeholderparticipation. Dr. Dort thanked Dr. Fildes for his presentation and asked for comments. Dr. Fisherasked if the assessment taskforce had certain metrics in mind such as transport times or trauma per population. Dr.Fildesrepliedthatattheoutsettheywouldstartwith lookingat itgloballyto determinetheneedsandmeasureable events. Henotedthata commonquestionaskediswhy Sunrise, a Level II trauma center, and UMC, a Level I trauma center are only three miles apart. He explainedthat in2004the DepartmentofHomelandSecuritypointedout Western Pacific Railroad'srightof way.The1-15 corridorandLasVegasBlvd. createsa geographic boundary that sometimespreventseast/westmovement of EMS personnel. So they need to exercisecommonsenseandanalyzethereasonsbehindtheirdecisionmaking. Ms.BreenexpressedconcernaboutUMC,aLevelItraumacenterthatsupportssomanyareas of the community, will end up with patients who don't have the ability to pay their bill, thereby putting the community at risk of losing UMC. They need to include that in the discussion when assessingthe needto expandthe trauma system. Dr. Fildes stated that in orderforUMCtodischargeitsdutiesitneedsafixednumberofpatients. Headdedthereisa double-edged sword with regard to healthcare financed around trauma. There are the fixed andvariablecostsof operatingatraumacenter,whichshouldreallybereferredto asthecost ofpreparedness. It's thereason wesupportandpolice andfiredepartment. Butit's important topayforthatpreparedness, andtohavethatinthecommunityasourpublic safetynet. Butif onefirehouse isgood,howabout3,000firehouses? Henotedthereisatippingpointinthere somewhere. With regard to healthcare financing in trauma at the national level, the federal government is the biggest payer. It didn't wantthe CDCto bringout trauma field triage criteriathat wouldproducean oversupplyofover-triagedpatientsthat wouldthen haveto be reimbursedbyMedicareandMedicaid. Theywantedto knowthat the numberoflivessaved isgoing to besustained orimproved; butalso thattheunneeded careinthesystem would be eliminated. Henoted thatthat's notthewaythependulum isswinging rightnow. Sooneof thebiggestrisks inthecommunity isn'treally totheLevel Itraumacenterorthepatients; it's the payergroups. RegionalTraumaAdvisoiyBoardMeetingMinutes Page10of15 Office of Emergency Medical Services & Trauma System Recommendation Regarding TraumaCenterApplications Mr. Hammond provided a presentation (Attachment E) on SNHD's recommendation to the Board. He stated the GEMSTS derives its authority from NRS 450B.231, wherein the District's Board ofHealth, in a county where the population is 700,000 or more, shall adopt regulations which establishes standards for the designation of hospitals in the county as centers for the treatment of trauma. The regulations are consistent with the regulations adopted by the State Board ofHealth pursuant to subsection 2 ofthat same law. With regard to the addition ofcenters for the treatment oftrauma to the system, Nevada Administrative Code(NAG)450B.828 statesthat for reasons includingbut without limitation, there must bea significant increase in the volume of patients with trauma served in the geographic distribution of the patients with access to existing centers for the treatment of trauma, or pediatric centers for the treatment oftrauma. Section 300 ofthe Trauma System Regulations, the GEMSTS' authority, states that any hospital that desires designation as a center for the treatment of trauma, or a pediatric center for the treatment of trauma, shall first request authorization from the Board ofHealth. The Board ofHealth shall determinethe needs ofthe Clark County trauma system based on evidence obtained through continuous evaluation, assessing volume acuity and geographicdistribution ofpatients requiring trauma care, andthe location, depth, and utilization of trauma resources within the system. Per the District Procedure for Authorization as a Center for the Treatment ofTrauma or Pediatric Center for the Treatment of Trauma, the applicant must demonstrate the need for additional trauma services at the level beingrequestedinthe proposedservice area includingthe populationwe serve,geographicconsiderationssuchasdistanceto existingcenters, andthe projectedimpact to the traumasystem. Mr. Hammond explained that the RTAB and TMAC provide continuous oversight of the trauma system through review ofthe EMS & Trauma System data, the Trauma Center data, engaging the participation ofboth public and private EMS agencies, rehabilitation facilities, and long-term care facilities. He reported that since 2010 the data has not shown an increase involumethat couldnotbemet bythe existingsystem. Since2010, EMSagencieshavenot indicated thatoutofservicetimes linked to traumacenter location ortraumacare transferwas an issue; and the GEMSTS has not received a complaint from the public or any provider regardingthe lack ofaccess to traumacare. Mr. Hammond referred the Board to a graph illustrating that the annual volume oftrauma patients has increased through the years from 2010 to 2015. However, the increase between 2013and2015 isatotalof260patients,whichdividedbetweentheexistingtraumacentersis approximately seven per month. He referred the Board to anothergraph illustrating trauma patientvolume bystepandyear. Thenextgraph illustratedtraumapatientvolume bystepand year. He notedtherewasnovirtuallynochangeinthe numberphysiologicalandanatomical patients. Withregardtopatientacuity anddisposition, thedatashownosignificantpercentile changessince2010. Patients arebeingseen,discharged, oradmitted totheoperating room or ICU at the samerateforthe lastsixyears. Themedian transport timeforallsteps inClark Countyfrom 2010to2015 isapproximately16minutesacrossthe board. Mr. Hammondremarkedthat the applicants have suggested that trauma center designation would imply that patients would receive care in their communities. He noted that in the "Resourcesfor GptimalCareofthe InjuredPatient2014," page49, the ACSstatesthat rural hospitals should endeavor to treattrauma patients intheircommunity as appropriate to the level ofresources available. And that, inremote areas, theLevel IIItrauma center may take on the responsibilityfor educationand system leadership. He noted that there is no similar statementregarding community, suburban, or urbansystems, and that the applicants are in suburbanareas, notruralareas,of LasVegas.TheACSresourcedocumentfurtherstatesthat Level III trauma centers are generally not appropriate in an urban or suburban area with adequate Level 1and/or Level IIresources. Henoted that,as inprevious examples, patients