Return On Investment: 30 Years Of Commitment To The Injured Child Has Become A Pathway To Success. J.J. Tepas III MD, FACS, FAAP
Korean Conflict • Air Ambulances • Vascular Repair • Return to Larrey (MASH) • ARF (Acute Renal Failure)
Return of a “ social agenda ” Wilbur Mills ’ “ Three layered Cake ” Medicare Part A – hospitalization Medicare Part B – physicians fees Medicaid – state shared coverage of poor 7/30/65
Vietnam Conflict Air Ambulances unopposed ARF solved (Shires/Moyer) New problem: Danang lung
From this point on, cost control!!! CPI 79.7% rise Hospital costs 237% rise! Chrysler: • $600 Million for healthcare • More than for steel and rubber • Inpatient maternity twice as long as average • Podiatrists: one toe at a time!
Civilian Trauma Systems
The Surgeon and The Injured Child
APSA May 1984 NPTR April 1 1985
Mt. Blanc / Imo 12/6/17 Halifax Harbor
Wesson et al Hospital for Sick Children
First Comparison of Pediatric to Adult Centers Harbinger?
Score Wars!!
Res esour ources ces an and d Training aining 1988
“ It ’ s hard to believe that once there was a time-even in this century – when retirement was nearly synonymous with poverty, and older Americans died in our streets. ” WJC, 9/22/93 1,342 pages of undecipherable technical jargon Harry and Louise take to the airwaves Republicans: against employer mandate, favor individual mandate! 1996 HIPAA – limit coverage denial 1997 SCHIP – uninsured children
REFORM’S “STRATEGIC” PLAN Track 1 Track 2 Cuts to Existing FFS System Transform Existing System • Market basket reductions • Bundled Payments • DHS cuts • Innovation Center • Nonpayment for anything Demonstrations preventable or Accountable Care unnecessary. Organizations
Cracks In The System Injury Delay Hypoxia Pre-hospital ?? procedures Wrong triage Cold Resuscitation Hypoxia Contamination Improper ventilation Evaluation Inappropriate studies Cold No leader Critical Care Fluid/Electrolyte anomaly PNA Slow D/C planning Convalescence Poor family support Out of sight, out of mind. Recovery
Trauma Systems “ If you build it, they will come ” DOES NOT APPLY! 2005: Pediatric Criteria 58 L1; 44 PTRC 24 L2; 21 PTRC 65; 41 out 14 New PTC
Poor Policy Invites Unintended Consequences Session: XI: Quickshots Paper QS16: 9:46-9:52 PEDIATRIC TRAUMA CENTERS AND AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA VERIFICATION: IMPACT ON MORTALITY Emily E. Murphy MD, Mark D. Cipolle* MD,Ph.D., Glen Tinkoff* MD, Stephen Murphy MD, Barry Hicks* MD, Gerard Fulda* MD, Christianacare Health Services Invited Discussant: Jeremy Cannon, MD Introduction: Pediatric mortality is lower in states with American College of Surgeons Committee on Trauma (ACS COT) verified pediatric trauma centers (PTC) compared to states without verified PTCs. We hypothesize that mortality rates will be lower for severely injured children cared for at a PTC that is ACS verified. Methods: Children ≤14 years old with an injury severity score (ISS) >15 were selected from the 2010 National Trauma Databank research dataset (NTDB RDS). Entries with missing ISS or age information were excluded. Patients who were dead on arrival were excluded. Univariate analysis was performed for age, gender, mortality, ACS adult verification and ACS pediatric verification. Significant variables were subsequently assessed by logistic regression. A subset analysis was performed on freestanding pediatric hospitals. A p-value of <0.05 was considered significant. Results: The 2010 NTDB RDS included 11,859 pediatric patients with an ISS > 15 . Univariate analysis was statistically significant for the primary outcome of mortality among the following variables: race, payment type, ISS, region, ACS adult verification and ACS pediatric verification. Other variables (gender, age, ethnicity, location of injury, hospital type and teaching status) were not statistically significant and were not included in logistic regression. The results of the logistic regression are displayed in table 1. ISS, region, race, payment and ACS pediatric level were significant among patients with an ISS >15. Subset analysis of freestanding pediatric hospitals demonstrated that ACS pediatric level (p=.007), ISS (p<0.001) and payment (p<0.001) had a significant impact on mortality, while region, race, gender and teaching status were non-significant. Conclusions: ACS pediatric verification is associated with decreased mortality of severely injured children in ACS verified adult trauma centers as well as in freestanding pediatric hospitals. ACS adult verification alone does not confer this mortality benefit. Race, payment and region are additional factors that impact pediatric trauma mortality. Pediatric ATLS?
Stewardship FMAP Cost shift = Fed & Premium rise. State Fed Taxpayer Taxpayer Phase Payer Acute INS, MCR, MCD, Subs Professional INS, MCR, MCD, ?Subs Care Rehabilitation INS, MCR Event Higher Co- Reintegration MCR-SSI, pay and Deductible = Chronic INS, MCR, MCD Medical Debt
Three Opportunities • Data: the glue that binds and the fuel that drives • Tele-medical Resuscitation Support • Care of the Injured Brain
Impact of Poor EMR Design 80% of encounters lack important information 60% of clinical questions go unanswered 50% of those answers would have had direct impact 33% of clinical time spent searching/organizing data 40% of clinical data resides in “ white space ”
Current Dysfunctional Clinical Data Ecosystem Limited data liquidity due to: Lack of interoperable data standards/API data infrastructure Limited business case for improved data flow and better quality for care 7
Functional Clinical Data Ecosystem Use Cases
Build APPS designed to use ecosystem to optimize surgical care! Data TO Surgeon Data FROM Stage Record Referring EMR SSR CMS Other NSQIP 1 Initial Assessment ACS ACS 2 Therapeutic Plan Devised THEN: ACS 3 Risk Calculation 4 Risk ACS Disease, Procedure, Review/Documentation “APP Specialty focused 5 Counseling/Consent suite” APPs 6 Pre-Surgery Care 7 Pre-op evaluation/review ACS 8 Intra-operative Care 9 PACU Care 10 Post-operative Care ACS 11 Follow-up Care 12 Long-term Management ACS FIRST: Surgical Continuum of Care APP
ABDOMIN DOMINAL AL I INJ NJURIES URIES Surgical Procedures – NPTR II&III Abdominal Surgery Organ Did Looked ExLap 1013 17 SB 349 Colon 199 Liver 154 Stomach 103 Appendix 97 Duodenum 68 Pancreas 35 Mes. Repair 35 Rect 22 Enteric Access Feed Jej 66 PEG 58 Gastrostomy 152 86 DPL 384
Splenic Trauma Upadhyaya & Simpson 1968 Howman-Giles, et al 1978 Wesson, et al 1981 SPLENIC INJURY MODERATE MASSIVE BLEEDING BLEEDING NO BLEEDING OR ASSOCIATED INJURY TRANSFUSION (UP TO 40ML/KG ) FURTHER BLEEDING (>40 ML/KG ) O.R. OBSERVATION
Splenic Procedures Partial Splenic Surgery splenectomy 10% Splenorraphy 36% Splenectomy 54%
Angiography status post proximal Angiography with two splenic artery embolization foci of active extravasation
Pediatric 11 0 (0%) 4 0 (0%) 1 (age<18) Adult 11 34 61 3(4.9%) 0.003* (age≥18) (32.4%) AE: Angioembolization; NOM: Non-operative management * p<0.05
• No role for AE in pediatric patients regardless of grade of injury • Reemphasizes that successful NOM in pediatric patients is based on hemodynamic stability alone
Blunt Abdominal Trauma: Spleen VS Liver
Results – Mortality Rates 9% 8% 7% 8.7% 6% 5% 4% 3% 2% 2.5% 1% 0.7% 0% Splenic Hepatic L/S n=2553 n=347 n=2543 p < 0.05 Hepato-splenic injury combination is a marker of even greater mortality potential.
Imaging: How To Decide?
Sustained OR Yes Hypotensive? Transient No Belly Pain? CT Positive Negative No Out Yes FAST Negative Positive Observe
As Low As Reasonably Achievable A BAT Acutely L Stable Unstable OR Tender A Distracted Non Tender Later Multiple or severe?” FAST R Non Specific Fluid CT Neg Non Renal Injury? POS A As ? Renal Injury Reason CDS Asserts
As Low As Reasonably Achievable A BAT Acutely L Stable Unstable OR Tender A Distracted Non Tender Later Multiple or severe?” FAST R Non Specific Fluid CT Neg Non Renal Injury? POS A As ? Renal Injury Reason CDS Dictates
Proposed Algorithm - Abdominal wall or lower chest bruising. Yes - Abdominal pain or tenderness. - Low blood pressue – not shock. No 1. Positive Ultrasound Yes No 2. Increased AST/ALT > 200/125. 3. Hematuria > 5 RBC/hpf. CT Scan Observe Pediatrictraumasociety.org
The Triumph of Reason Over Ritual Start N Is the patient stable? O Y Y Free Air on Cxr? R N Y Peritonitis? N Y NEG Is the belly tender? Clinical N Evaluation FAST Bleeding in the belly? Y d N POS e Y Patient distracted? CT N e=expeditious d=delayed END
What happens to the brain cells after TBI? Head Injury/Primary Injury Biological Response/ Secondary Injury We are here! Cell Injury/Cell Death Suppressed Cellular Function Cognitive Impairment/ Motor Disability
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