CCMSD trauma team to mentor WY hospitals

State asks team to share the secret of their success


March 19, 2020

The heads of Crook County Medical Services’ trauma team were set to attend a national conference in Ohio this April, to share their knowledge of how to transform and improve a trauma unit in a small rural hospital. Unfortunately, along came the coronavirus and the conference was canceled.

While they wait to appear on next year’s agenda, Bob Hart, Warren Shaulis and Heath Waddell will still have the chance to share their expertise. State officials were so impressed by the improvements that have been made to the trauma unit that they asked its three leads to guide struggling small hospitals in Wyoming towards better success.

“We’ve turned things around through some interesting methodology,” says Shaulis. Numerous small changes have been made to get more organized and cut down on “dwell times”, says Hart.

This refers the amount of time between a trauma patient coming into the ER and when they leave, having been stabilized to the point where they can be sent for surgical aid; Crook County’s dwell time used to sit at around three or four hours.

“That’s a long time, and the state benchmark is two hours for critical access,” says Hart. “As of last year, I think statewide they are hitting an average around 28% of the transfers that occur in the State of Wyoming are happening in two hours or less. Last quarter, we hit 100%.”

Dwell times have been improved incrementally, refining the process over time, Hart says. Each case that comes through the ER is examined and the team asks where things could be changed.

“There is not one department in this hospital that doesn’t participate,” he says. “Everybody is involved.”

One element of the improvement process, says Shaulis, “Is the methodology that we’ve used to do quality improvement: how do we fix the problems that the state identifies when they come in?”

Another is the paramedics added to the permanent staff a couple of years ago.

“We used to have one paramedic who worked here and he was on call 24/7, 365,” Shaulis says. “Now we have six paramedics and what we’re doing is utilizing them in the emergency department as well, and in the hospital.”

The team has practiced streamlining its process through training exercises, some of which have included LifeFlight® to figure out the most seamless transition process possible. Thanks to that partnership, says Hart, the team has been able to shave off even more time by activating LifeFlight as soon as a serious-sounding trauma report goes out over dispatch channels.

“We’ve got a good relationship with them and they welcome us to just launch them and send them, because it’s a good 45 or 50 minutes before you’re going to see them here,” Hart says.

The team will never stop trying to improve – it’s about continuous quality improvement, Shaulis says. The aim is to meet nationwide benchmarks and standards from such institutions as the American College of Surgeons as to “how should you treat trauma patients in the United States.”

The trio feel that three things have made the transformation at CCMSD possible: medical personnel being flexible in their thinking; the sharing of ideas from diverse sources; and the district’s leadership from the board of trustees all the way down.

The Rural Challenge

Trauma at an emergency level is defined as a significant injury that could cause long term disability or death. A big hospital in Denver or New York City will treat trauma patients in a manner appropriate to the fact that they have surgery options immediately available.

Rural hospitals are different, Shaulis explains: the goal is to make sure the patient is in the best possible state to be sent to where surgery can take place.

“90% of the [U.S.] population lives within an hour to an hour and a half of a level one trauma center,” says Shaulis; the closest to Crook County is in Denver, while Rapid City has a level two.

A surgeon on staff not usually possible in rural areas, but trauma patients still need surgical aid.

“It’s not something you can manage medically. You can’t give somebody a shot to reverse trauma,” Shaulis says. “If you have a ruptured spleen then you have to go in and take the spleen out, you can’t give somebody an injection to heal it.”

It’s the role of a rural critical access facility to ensure the patient is stabilized so they can safely be taken to a surgeon. This is a time-sensitive process that’s all about doing as much as can be done in as little time as can be managed.

“How do we help maximize that patient’s potential for survival? Part of that is dwell times, part is early initiation of airway management, of giving blood products,” Shaulis says. “There’s things we can do, and we have to play our part and then move them on to the next tier of care.”

Care Elsewhere

State officials asked the trio to speak at the National Rural EMS and Care Conferences to offer new ideas to small hospitals further afield than Wyoming. The event is sponsored by the National Organization of State Offices of Rural Health (NOSORH).

NOSORH encourages information-sharing across the nation, says Hart. A small hospital in another part of the country may be experiencing different traumas – we don’t have many scorpion stings in Crook County, for instance – but challenges like small budgets and long distances to a higher level hospital are identical no matter the geography.

“You have to be creative to get more done with less,” says Hart.

What these conferences are about, says Shaulis, is, “How are people innovating?” The team would have spoken about the methods they used to do exactly that.

“There are places in the rural United States that have not developed even a trauma team,” Hart says. “Here, we have a trauma alert that we call and the team assembles, everybody knows their role because it’s assigned every morning. You have to show people how to set up these processes and make it easier for them so they don’t have to reinvent the wheel all by themselves.”

Though the conference was cancelled, Hart says, “We’re already in the process of helping some of the other critical access hospitals in the state.”

“They’re just starting to develop a program, so I share a lot of stuff with them that has taken us years to develop and refine,” Hart says. “They may have to adjust it a little bit because their geography and resources are going to be different and their people live in different places and they may have slightly different capabilities, but here’s the roadmap.”


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