COMPLETED BOARD REPORT"�|E���MONTEREY COUNTY BOARD OF SUPERVISORS
MEETING: June 14, 2011
AGENDA NO: Consent
3a
SUBJECT: Approve and authorize the Emergency Medical Services Agency Director to submit
the revised Monterey County Trauma System Care Plan to the California State Emergency
Medical Services Authority.
DEPARTMENT: Health Emergency Medical Services Agency
RECOMMENDATIONS:
It is recommended that the Board of Supervisors:
Approve and authorize the Emergency Medical Services Agency Director to submit the revised
Monterey County Trauma System Care Plan to the California Emergency Medical Services
Authority.
SUMMARY:
The Monterey County Emergency Medical Services EMS) Trauma Care System Plan was
developed in 2007 and is being revised in 2011 in compliance with the State of California Health
and Safety Code Division 2.5 Sections 1797.257 and 1797.258 Trauma Statutes) and the
California Code of Regulations Title 22 Social Security Division 9 Prehospital Emergency
Medical Services Chapter 7 Trauma Care Systems Trauma Regulations) and the Monterey
County Emergency Medical Services Plan. The revised Monterey County Trauma Care System
Plan outlines the structure and operations of the proposed trauma care system within Monterey
County. This revision incorporates a design change from no Trauma Centers in Monterey
County to the designation of a Level II Trauma Center.
Specifically, the plan incorporates procedures for system operations, which meet the minimum
standards in the regulations and establishes a timeframe for change implementation. In addition,
support policies and protocols have been identified and are being developed pursuant to Section
100255, Title 22, CCR. Upon your direction, the revised Monterey County Trauma Care System
Plan, and applicable policies and protocols will be submitted to the California EMS Authority by
the EMS Director.
DISCUSSION:
Currently, the majority of trauma patients require air transport to Santa Clara County Trauma
Centers. Mechanism-Anatomical-Physiological MAP) triage criteria algorithm) are used
within Monterey County to determine injury severity and when the patient meets MAP criteria, a
helicopter is dispatched and patients are transported to Santa Clara County.
Monterey County Emergency Medical Services Agency seeks to improve the care provided to
trauma patients in its service area through an inclusive trauma care system. The proposed system
design includes:
The designation of a Level II Trauma Center.
Trauma patients within 45 minutes via ground or air) of the Monterey County Level
II Trauma Center will be transported directly to that facility. All other patients will
be transported to the destination determined by the Level II Trauma Center;
Appropriate patients will be transported to a designated pediatric Trauma Center in
another county;
A quality improvement process will be established which includes appropriate
stakeholders;
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COMPLETED BOARD REPORT"�|E��� Appropriate policies will be adopted for implementation and operation of the system;
and,
Training will be provided for prehospital and hospital personnel regarding the
changes to system policies including field trauma triage and hospital destination.
OTHER AGENCY INVOLVEMENT:
On April 13, 2011, the revised Monterey County Trauma Care System Plan was reviewed and
endorsed by the Emergency Medical Care Committee EMCC), which was established by the
Board of Supervisors to represent the interests of local EMS stakeholders, and to serve in an
advisory capacity to both the Board and the Director of Health. The April EMCC meeting also
allowed for public comment to the plan. A copy of the 2011 Monterey County Trauma Care
System Plan is on file with the Clerk of the Board.
FINANCING:
Development and revision of the Monterey County Monterey County Trauma Care System Plan
was funded through County Service Area 74. There is no financial impact on the General Fund
Contribution to EMS with this recommended action.
Preparedly: Approved
Kirk Schmitt
Director EMS Agency
Date: April 13, 2011
Ray Bullick
Director of Health
Date: 513tit I
Attachments: 2011 Monterey County Trauma Care System Plan on file with Clerk to the Board
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COMPLETED BOARD ORDER"�|E��!�37
Before the Board of Supervisors in and for the
County of Monterey, State of California
Approve and authorize the Emergency
Medical Services Agency Director to
submit the revised Monterey County
Trauma Care System Plan to the California
Emergency Medical Services Authority.....
Upon motion of Supervisor Salinas, seconded by Supervisor Armenta, and carried by
those members present, the Board hereby;
Approved and authorized the Emergency Medical Services Agency Director to submit the
revised Monterey County Trauma Care System Plan to the California Emergency Medical
Services Authority
PASSED AND ADOPTED on this 14th day of June, 2011, by the following vote, to wit:
AYES: Supervisors Armenta, Calcagno, Salinas, Parker, and Potter
NOES: None
ABSENT: None
1, Gail T. Borkowski, Clerk of the Board of Supervisors of the County of Monterey, State of California, hereby
certify that the foregoing is a true copy of an original order of said Board of Supervisors duly made and entered
in the minutes thereof of Minute Book 75 for the meeting on June 14, 2011.
Dated: June 17, 2011 Gail T. Borkowski, Clerk of the Board of Supervisors
County of Monterey, State of California
Deputy
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COMPLETED BOARD ORDER"�|E��!�Monterey County
Emergency Medical Services Agency
TRAUMA CARE SYSTEM PLAN
Revised April 2011
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COMPLETED BOARD ORDER"�|E��!�Authority and purpose 1
1. Summary of the plan 2
II. Organizational structure 3
Ill. Needs assessment 4
IV. Trauma system design 5
A. Revised system design 5
B. Rationale for trauma system design and for number and location of trauma
centers 6
C. Policies developed pursuant to Section 100255 9
VI. Objectives 14
VII. Implementation schedule 16
VIII. Fiscal impact of the system 17
IX. Policy and plan development process system 18
X. Written documentation of local approval 19
XI. Locations of required information 20
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COMPLETED BOARD ORDER"�|E��!�April 2011
AUTHORITY AND PURPOSE
The Monterey County Emergency Medical Services EMS) Trauma Care System Plan was
developed in 2007 and revised in 2011 in compliance with the State of California Health
and Safety Code Division 2.5 Sections 1797.257 and 1797.258 Trauma Statutes) and the
California Code of Regulations Title 22 Social Security Division 9 Prehospital Emergency
Medical Services Chapter 7 Trauma Care Systems Trauma Regulations) and the
Monterey County Emergency Medical Services Plan_ The revised Monterey County
Trauma Care System Plan outlines the structure and operations of the proposed trauma
care system within Monterey County. This revision incorporates a design change from no
Trauma Centers in Monterey County to the designation of a Level II Trauma Center.
Specifically, the plan incorporates policies and procedures for system operations, which
meet the minimum standards in the regulations. Finally, it establishes a timeframe for
implementation of system changes.
The Monterey County Emergency Medical Services Agency, would like to thank all of the
individuals, organizations, and institutions that assisted in the development of this Plan.
Monterey County Trauma Care System Plan Page 1
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COMPLETED BOARD ORDER"�|E��!�April 2011
1. SUMMARY OF THE PLAN
The Monterey County EMS Trauma Care System Plan was developed in compliance
with Trauma Statute and Regulations.
A. Organizational structure:
Monterey County EMS Agency is a local emergency medical services agency
designated by the Monterey County Board of Supervisors via resolution 79-202 dated
April 24, 1979.
B. Needs assessment:
Currently, the County system of care for trauma patients is to air transport the majority of
trauma patients to Santa Clara County Trauma Centers. Mechanic-Anatomic-
Physiologic MAP) triage criteria algorithm) are used within Monterey County to
determine injury severity and when the patient meets MAP criteria, a helicopter is
dispatched and patients are transported to Santa Clara County.
C. Trauma system design:
Monterey County EMS seeks to improve the care provided to trauma patients in its
service area through an inclusive trauma care system. The proposed system design is:
The designation of a Level II Trauma Center.
Patients meeting field triage criteria will be transported to a Level II Trauma
Center in county when possible;
Appropriate patients will be transported to a designated pediatric Trauma Center
in another county;
A quality improvement process will be established which includes appropriate
stakeholders;
Training will be provided for prehospital and hospital personnel regarding the
changes to system policies including field trauma triage and hospital destination;
Appropriate policies will be adopted for implementation and operation of the
system; and,
Trauma patients within 45 minutes via ground or air) of the Monterey County
Level II Trauma Center will be transported directly to that facility. All other
patients will be transported to the destination determined by the Level II Trauma
Center.
Monterey County Trauma Care System Plan Page 2
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COMPLETED BOARD ORDER"�|E��!�April 2011
II. ORGANIZATIONAL STRUCTURE
The Monterey County Emergency Medical Service Agency EMS) is an agency created
and governed by the Monterey County Board of Supervisors via resolution 79-202 dated
April 24, 1979. A map of Monterey County is provided in Appendix A California
County Map.
Current Organizational Structure
Board of Supervisors
EMCC
EMS Operations
Committee
EMS Medical
Director
Medical Advisory
Committee
Trauma Audit
Committee
County Administrative Officer
Director of Health
Emergency Medical Services Director
Health Officer
Emergency Medical Services/Agency Staff
QI/Trauma Coordinator
Monterey County Emergency Medical Care Committee EMCC), created by the Board of
Supervisors in 2002, acts in an advisory capacity to the Board of Supervisors and the EMS
Director in regards to operational and medical issues. Per the April 6, 2010, the EMCC
bylaws BOS Resolution #10-069), the EMCC shall advise the Board of Supervisors and
EMS Director on EMS system issues, including CSA74 funding, the EMS Agency budget,
and training; ensure that all EMS constituents will be actively engaged in decisions
regarding EMS system resources; and provide input on the development and
implementation of County EMS policies, protocols, and procedures.
The Monterey County EMS Agency utilized the Medical Advisory Committee with
expanded participation see Appendix I Medical Advisory Committee Membership) to
provide leadership in the development of the Monterey County Trauma Care System Plan
and to provide a mechanism for input from system stakeholders and constituents.
Legend:
Direct Report
Advisement
Monterey County Trauma Care System Plan Page 3
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COMPLETED BOARD ORDER"�|E��!�April 2011
111111. NEEDS ASSESSMENT
Currently, many trauma victims are transported to Santa Clara County via helicopter.
Patient who are transported to Santa Clara County have data collected by Santa Clara
County. Data is not collected regarding triage, transport, treatment or disposition of
trauma patients who remain in Monterey County. For the purpose of the creation of the
2007 Trauma Care System Plan, significant research was done to identify trauma
patients for 2003. However, since 2007 there data has been not been collected
regarding trauma patients remaining in Monterey County.
A summary of the 2007 data collection is shown in Appendix B Trauma System
Volume. The population of Monterey County has increased by an estimated 7,300 since
the 2007 Trauma Care System Plan was created; the population increase will not
significantly change the anticipated trauma volume for the current revision.
Appendix C Trauma System Resource Assessment identifies the resources
available for trauma care within Monterey County. The closest tertiary level services,
other than cardiac care, are in San Francisco and Santa Clara Counties. While there are
four acute care hospitals in the Monterey County, until recently none of the hospitals
expressed an interest in being designated a trauma center. Salinas Valley Memorial
Healthcare System has initiated discussions about Level II designation. Community
Hospital of the Monterey Peninsula has several procedures in place for receiving trauma
patients. Natividad Medical Center is interested in trauma but at this time is unable to
commit resources to meet the standards for designation.
Beds ED ICU OR
Community Hospital of the Monterey 201 24 20 8 rooms anesthesia and RNs
Peninsula City of Monterey) on call after 2330 hours)
Mee Memorial Hospital 119 6 4 3 on call after hours)
City of King)
Natividad Medical Center 172 19 10 4 OR crew on call after 1800
City of Salinas) hours)
Salinas Valley Memorial Healthcare 269 20 13 7 on call after 2300 hours)
Systems City of Salinas)
Monterey County Trauma Care System Plan Page 4
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COMPLETED BOARD ORDER"�|E��!�April 2011
IV. TRAUMA SYSTEM DESIGN
Monterey County EMS seeks to improve the care provided to trauma patients in its service
areas through designating a Level II Trauma Center. The proposed system design is:
Designating a Level II trauma center;
Patients meeting field trauma triage criteria will be transported to the Level II
Trauma Center when appropriate;
Appropriate patients will be transported to a pediatric Trauma Center in another
county;
A quality improvement process will be established which includes stakeholders;
Training will be provided for prehospital and hospital personnel regarding field
trauma triage policies, trauma patient destination, and other system policies;
Appropriate policies will be adopted for implementation and operation of the
system; and,
Trauma victims within 45 minutes via ground or air) of the Monterey County
Level II Trauma Center will be transported directly to that facility. All other
patients will be transported to the destination determined by the Level II
Trauma Center.
A. Revised system design
Level II Trauma Center: Monterey County EMS intends to designate a Level II
Trauma Center.
Patient flow: Trauma victims within 45 minutes of the Level II trauma center will be
transported directly to that facility. All other patients will be transported to the
destination determined by the Level II Trauma Center.
Quality management: Monterey County's Level II Trauma Center will maintain
internal quality assurance programs meeting state and county standards. Monterey
County EMS will have a Trauma Coordinator who, along with the EMS Medical
Director, will be responsible for evaluating the trauma system's protocols, policies
and procedures for appropriateness; reviewing, analyzing, and evaluating trauma
case reports for system effectiveness; serving on and participating in the Trauma
Audit Committee in Monterey County; and otherwise provide leadership related to
trauma care. See the Trauma Quality Improvement and System Evaluation Policy
for additional information.
Monterey County Trauma Care System Plan Page 5
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COMPLETED BOARD ORDER"�|E�� !�April 2011
B. Rationale for trauma system design and for number and location of trauma
centers
The number of Trauma Centers needed in the system is based on four criteria:
MINIMUM PATIENT LOAD: Each designated trauma center must receive
a sufficient number of major trauma patients to maintain a high skill level.
California's Trauma Care System Regulations require a minimum
population of 350,000 for each Level I or Level II trauma center to be
designated. An exception can be granted for the 350,000 population per
Level I or II Trauma Center designation by the EMS Commission.
PATIENT TRANSPORT TIMES: If an area of the County is not within a
reasonable distance from a designated Trauma Center, and if patient load
permits, an additional Trauma Center should be considered. Both ground
and air transport times must be considered.
RESOURCE AVAILABILITY: Within each potential trauma service area,
there must be a hospital or hospitals with the interest in and capability of
meeting the minimum standards for Trauma Center designation, as
provided for in the trauma regulations.
RESOURCE REQUIREMENTS: Each trauma care system should have
the total number of trauma teams, including personnel and facilities,
necessary to care for the projected patient load.
These criteria have been applied to the Monterey County EMS trauma system as
follows:
Patient load: According to the California Department of Finance, the Monterey
County EMS region has an estimated 2010 permanent population of 435,878. A
population density map is provided as Appendix D Population Density Map of
Monterey County. Due to the geography and population center, it is not anticipated
that counties surrounding Monterey County would contribute any significant volume
of trauma victims. Monterey County might receive a few patients from San Benito
County when helicopters are unable to fly and it is possible that a few patients might
be routed from southern Santa Cruz County. The rule of thumb" of one trauma
patient for every 1,000 population suggests an estimate patient load of 436 per
year. Based on the data reviewed in 2006, the number of trauma patients is
expected to support the 436 per year estimate.
Some patients from within the Monterey Region are closer to Trauma Centers in
other systems. Patients from the southeast portion of the County may be closer to
a Trauma Center located in Fresno County.
The current population would allow for designation of one Level II Trauma Center.
Monterey County Trauma Care System Plan Page 6
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Transport times: The Monterey County EMS Trauma Care System includes 3,325
square miles. The majority of the population for the County is located in the
northwestern portion of the county with the largest city, Salinas, located
approximately ten 10) miles east of Monterey Bay. Other population centers are
found along the coast in the cities of Monterey, Pacific Grove, Seaside, Marina and
Carmel. In addition, some residents and tourists/visitors to the Monterey County are
located in rural, remote, or wilderness areas; and are distant from healthcare
facilities and medical resources See Tables 1 and 2 below):
Table 1: Travel Times from Monterey County Communities to Out-Of-Coun Trauma Centers
Community Trauma Center Ground Air Surface
Destination miles/minutes a m iles/minutes b
Big Sur Regional Medical 100/105 minutes 76/33 minutes
Center RMC) of
Santa Clara
King City RMC 106/105 minutes 89/38 minutes
Lake San Antonio RMC 128/143 minutes 103/44 minutes
Recreation Area
Lockwood)
Lucia RMC 125/134 minutes 94/40 minutes
Monterey Peninsula RMC 71/73 minutes 52/23 minutes
Airport
Pinnacles RMC 76/99 minutes 75/33 minutes
Parkfield University Medical 100/138 minutes 86/37 minutes
Center Fresno
Salinas Natividad) RMC 60/64 minutes 47/21 minutes
Tassajara Hot Springs RMC 108/149 minutes 61/26 minutes
a. Source: Mapquest
b. CALSTAR Google Earth
Table 2: Travel Times from Monterey Coun
Communities to In-Coun
Trauma Center
Community Trauma Center Ground
Destination miles/minutes)a
Big Sur CHOMP� 29/42 minutes
SVMHSd 49/68 minutes
King City CHOMP 67/76 minutes
SVMHS 47/52 minutes
Lake San Antonio CHOMP 110/131 minutes
Recreation Area SVMHS 90/107 minutes
Lucia CHOMP 52/71 minutes
SVMHS 73/97 minutes
Monterey downtown) CHOMP 3/6 minutes
SVMHS 19/29 minutes
Pinnacles CHOMP 70/83 minutes
SVMHS 58/77 minutes
Parkfield CHOMP 132/159 minutes
SVMHS 112/135 minutes
Monterey County Trauma Care System Plan Page 7
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Salinas Natividad) CHOMP 26/29 minutes
SVMHS 2/8 minutes
Tassajara Hot Springs CHOMP 42/110 minutes
SVMHS 46/112 minutes
a. Source: Google
b. CALSTAR Google Earth
C. CHOMP Community Hospital of the Monterey Peninsula
d. SVMHS Salinas Valley Memorial Healthcare System
Resource availability: Monterey County has four acute care hospitals. Two of these
are located in the City of Salinas, one is located in the City of Monterey, and the
fourth hospital is in King City south/central portion of the county). Only Natividad
Medical Center in the City of Salinas and Mee Memorial in King City have functional
helipads.
Resource requirements: The Monterey County EMS designation process would
assess and ensure that the designated Level II Trauma Center has a sufficient
number of trauma teams; including personnel and facilities to care for the projected
patient load as per Trauma Regulations. Without a designation site visit to ascertain
this information, it is not clear that either Salinas Valley Memorial Healthcare
System SVMHS) or Community Hospital of the Monterey Peninsula CHOMP)
have enough dedicated trauma surgeons and other specialties to meet resource
requirements of the Trauma Regulations.
Coordination with neighboring trauma systems: Santa Clara County allows patients
from Monterey County to routinely be transported to their Level I and Level II
Trauma Centers. Monterey County EMS will work with Santa Clara County to
clarify policies for tertiary services at their Level I and pediatric facilities to support
patients from Monterey County. Patients in southeastern Monterey County may be
transported to the University Medical Center of Fresno.
Monterey County abides by policies set by the region designating these centers.
Pre-hospital provider training: Monterey County EMS will conduct training for pre-
hospital providers to ensure that they are appropriately trained in all trauma system
related policies, including field trauma triage and hospital destination. The Monterey
County EMS Agency will develop trauma care system training for all emergency
medical responders, emergency medical technicians, paramedics, and hospital
personnel.
Communication equipment: Monterey County EMS requires that all ambulances be
equipped with two-way radios with appropriate frequencies for medical control and
hospital notification. See Appendix E Excerpts from Ambulance Ordinance
No. 5138; dated 9/22/2009)
Hospital notification: The Monterey County EMS field trauma triage criteria states a
member of the prehospital transport crew MUST notify the receiving facility
IMMEDIATELY when a major trauma victim is being transported."
Monterey County Trauma Care System Plan Page 8
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C. Policies being developed pursuant to Section 100255, Title 22, CCR and will
support the Monterey County Trauma Care System Plan.
Required area
System organization and
management:
Data collection and
management
Establishment of service
areas for trauma centers
Coordination of EMS and
trauma system for
transportation including
inter-Trauma Center
transfer and transfers
from a receiving hospital
to a Trauma Center
Monterey County EMS Policies
and Procedures Manual
Trauma Care System Organization and
Management Policy
This policy outlines the responsibilities Monterey
County EMS has as a lead agency in planning,
implementing and managing the trauma system.
This policy identifies the relationship with the Level II
trauma center and the participation of Monterey
County receiving facilities.
Trauma Data Collection and Management Policy
The purpose of this policy is to standardize the
reporting of trauma care and system information
gathered from the Trauma Center and other
receiving facilities in Monterey County.
Trauma Service Area Policy
This policy defines the trauma service area of
Monterey County as the whole county.
Trauma Patient Interfacility Transfer and
Transportation Policy
The purpose of this policy is to facilitate transfer of
trauma patients to the most appropriate facility. The
policy recommends receiving facilities have
agreements to facilitate transfers.
In addition this policy requires a designated Trauma
Center have agreements for pediatric patients, burn
and spinal cord victims transfer.
EMS Aircraft Operations Policy
The purpose of this policy is to set guidelines for the
field transport of major trauma victims MTV). The
policy recommends all patients considered MTVs
Monterey County Trauma Care System Plan Page 9
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Quality improvement and
system evaluation to
include responsibilities of
the multidisciplinary
trauma peer review
committee
Trauma care coordination
with neighboring
jurisdictions, including
EMS agency/system
agreements
Fees, including those for
application, designation
and redesignation,
monitoring and
evaluation
Trauma Center
designation/
redesignation process to
include a written
agreement between the
local EMS agency and
the Trauma Center
Coordination with health
maintenance and other
managed health care
organizations within the
trauma system to
facilitate the transfer of
an organization member
who are further than 45 minutes by ground transport
be flown to a Trauma Center if a helicopter is
available and travel time requirements are met.
Trauma Quality Improvement and System
Evaluation
This policy establishes and outlines in detail
Monterey County EMS Trauma Quality Improvement
program. It defines and outlines the various
responsibilities and processes for internal quality
improvement and external quality improvement.
Mutual Aid and Coordination with Neighboring
Systems Policy
This section of the policy ensures that patients are
transported to the nearest appropriate trauma center
despite geopolitical boundaries. Monterey County
EMS will have written mutual aid agreements with
neighboring EMS systems. Monterey County EMS
will maintain contact with neighboring EMS agencies
to monitor their status, contact these systems if
patients are to be transported outside the EMS
system, and will attempt to seek patient information.
Trauma System Fees
This policy describes fee setting process for the
application, designation and redesignation of a Level
II Trauma Center
Trauma Center Designation and Redesignation
Policy
This policy describes the application, designation
and redesignation processes for a Level II Trauma
Center.
Trauma Center Coordination with Health
Systems
This policy sets guidelines for trauma center
coordination with health maintenance and other
managed health care organizations within the trauma
service area.
Monterey County Trauma Care System Plan Page 10
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Integration of pediatric
hospitals, including
pediatric triage criteria if
applicable
Trauma Center
equipment
Assuring the availability
of trauma team personnel
Criteria for activation of
trauma team
Mechanism for prompt
availability of specialists
Field criteria for pediatric
and adult trauma triage
All pre-hospital providers
shall have a policy
approved by the local
EMS agency for the early
notification of Trauma
Centers of the impending
arrival of a trauma
patient.
Trauma Patient Interfacility Transfer and
Transportation Policy
The purpose of this policy is to facilitate transfer of
trauma patients to the most appropriate facility. The
policy recommends receiving facilities have
agreements to facilitate transfers.
In addition this policy requires a designated trauma
center have agreements for pediatric patients, burn
and spinal cord victims transfer.
Trauma Center Standards
This policy outlines the equipment capabilities
needed for designation of a Level II Trauma Center.
Trauma Team Availability And Activation
This policy outlines which trauma team members
need to be immediately available and their required
response times after prehospital notification.
Trauma Centers must have response policies and
procedures that include which position is responsible
for notification and procedures for notifying the
trauma surgeon, activating the trauma team,
mobilizing backup trauma teams and personnel, and
documentation of compliance with this policy.
Field Trauma Triage Policy
This policy sets field triage criteria including
physiologic factors, anatomic factors, mechanism of
injury and age and co-morbid factors. Specific
pediatric factors are also defined.
Field Trauma Triage Policy
This policy states that a member of the pre-hospital
crew must notify the hospital from the scene
immediately when a trauma alert is suspected. This
policy outlines the physiologic factors, anatomic
factors, mechanism of injury and age and co-morbid
factors that are the criteria for a trauma alert.
Monterey County Trauma Care System Plan Page 11
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Training of pre-hospital
EMS personnel to include
trauma triage
Public information and
education about the
trauma system
Marketing and
advertising by Trauma
Centers and prehospital
providers as it relates to
the trauma care system
Coordination with public
and private agencies and
Trauma Centers in injury
prevention programs
All trauma patient
transport vehicles shall
be equipped with II-way
telecommunications
equipment capable of
accessing hospitals, in
accordance with local
EMS agency policies
regarding
communication.
Provider Agreement: Required Training
Monterey County EMS provider agreement requires
that the provider training to their personnel on all
Monterey County EMS policies and protocols.
Per AMR Agreement Section 7.2.2)
Trauma Center Standards
This policy describes the Trauma Center standard
for providing public information and education about
the trauma system
Trauma Marketing and Advertising
This policy describes the advertising a designated a
Trauma Center can do and the approval process.
Trauma Center Standards
This policy describes the Trauma Center standard
for coordination with public and private agencies and
trauma center injury prevention programs.
Ambulance Ordinance Appendix E; Monterey
County Ordinance No. 5138.
Monterey County Trauma Care System Plan Page 12
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V. INTERCOUNTY TRAUMA CENTER AGREEMENTS
Currently the majority of trauma patients in Monterey County are air transported to Santa
Clara County trauma centers. Monterey County EMS works with Santa Clara County EMS
to ensure trauma patients receive appropriate care including participating on the Santa
Clara County Trauma Audit Committee. While both counties have an on-going dialogue
regarding trauma, the development/approval of a Memorandum of Understanding MOU)
remains outstanding.
At this time the volume of patients going to Fresno County is less than five 5) per year and
no agreement will be sought with Central California EMS Agency. In the future, if the
volume to these counties exceeds ten 10) patients per year, Monterey County EMS will
initiate communications with the Central California EMS Agency.
Monterey County Trauma Care System Plan Page 13
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VI. OBJECTIVES FOR IMPLEMENTATION
Objective #1: Approve the revised Trauma Care System Plan
By June 2011, Monterey County will revise the current Trauma Care System Plan with the
expanded Medical Advisory Committee; hold public hearings on the revised Trauma Care
System Plan; receive the endorsement from the Monterey County Emergency Medical
Care Committee; forward the revised plan to the Board of Supervisors for approval; and
submit to the California Emergency Medical Services Authority.
Objective #2: Adopt Trauma Policies
By September 2011, in concert with the Medical Advisory Committee, correct and/or
develop policies as required to support the revised Monterey County Trauma Care System
Plan; obtain the approval for implementing subject policies from the EMS Medical Director;
and forward subject policies to the EMS Authority.
Objective #3: Trauma Center Designation
A Level II Trauma Center designation process will begin in the Fall of 2011 with the intent
to designate one Level II Trauma Center. The start-up date for the revised Trauma Care
System Plan implementation will be based upon trauma center designation.
Objective #4: Training Plan
Prior to the implementation of the revised Trauma Care System Plan, all system
components will require training in the new and revised policies and procedures. It is
anticipated that training will begin upon trauma center designation. A mechanism for
training incoming employees for each of EMS component affected by the Trauma Care
System Plan and policies will be accomplished through Trauma Center personnel, field
training officers FTOs), and/or interactive CD ROM.
Obiective #5: Trauma Data Collection
A. Trauma data will be collected for all patients, including victims transported to the
Coroner, Monterey County Trauma Centers or hospitals, or out-of-county Trauma
Centers.
B. Monterey County will have a trauma registry consistent with the Santa Clara County
EMS registry. Appropriate Monterey County EMS Agency staff will be trained in the
use of the registry.
C. The EMS Medical Director will have participated in a trauma registry introduction.
D. A truncated data abstract form designed by the trauma registry vendor will be used
for trauma patients transported to non-Trauma Center hospitals or the Monterey
County Coroner.
Monterey County Trauma Care System Plan Page 14
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This objective will begin upon trauma center designation and be continuous.
Objective #6: Trauma Quality Improvement Process
Trauma quality improvement will consist of in-county monitoring and conducting bimonthly
case reviews by the EMS Agency Staff, EMS Medical Director, and the Medical Advisory
Committee.
This objective will begin upon trauma center designation and be continuous.
Monterey County Trauma Care System Plan Page 15
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VII. IMPLEMENTATION SCHEDULE
Objective Completion Date
Objective #1: Approve the revised Trauma Plan June 2011
Objective #2: Adopt Trauma Policies September 2011
Objective #3: Trauma Center Designation Upon trauma center
designation
Objective #4: Training Plan Upon trauma center
designation
Objective #5: Trauma Data Collection Continuous
Objective #6: Trauma Quality Improvement Process Continuous
Monterey County Trauma Care System Plan Page 16
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COMPLETED BOARD ORDER"�|E��!�April 2011
VIII. FISCAL IMPACT OF THE SYSTEM
The fiscal impact of the system is based on the marginal changes that would be required
to implement the system. These include the costs of meeting identified trauma system
requirements but do not include the costs of actual care provided to trauma patients.
In order to monitor trauma patient care, data must be collected. The Level II Trauma
Center would be required to submit trauma data and reports via an approved registry.
Non trauma center hospitals will provide ED patient disposition on patients identified as
meeting trauma triage criteria or for those trauma patients admitted to the OR, ICU or kept
more than 24 hours on the floor. Minimal data collection will be requested. Monterey
County will collect this information quarterly.
On-going Expense Frequency Annual Cost
Trauma Coordinator
CN Coordinator) 0.5 FTE with benefits
$60,043.60
EMS Analyst 0.5 FTE with benefits $60,043.60
EMS Medical Director 0.1 FTE $34,000.00
Total $154,086.40
No data is currently available on the fiscal benefits from implementing a local Trauma Care
System, however, benefits seen in similar systems include decreased morbidity and
mortality; decreased length of hospital stay; and early return of patients to a productive life.
Monterey County Trauma Care System Plan Page 17
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IX. POLICY AND PLAN DEVELOPMENT PROCESS SYSTEM
The Monterey County EMS Trauma Care System Plan was reviewed and revised with
participation from many interested parties. Since January 2011, the progress of the
planning process has been reported and discussed at the Medical Advisory Committee
and Emergency Medical Care Committee. After approval of the draft plan by the Medical
Advisory Committee with expanded participation, the plan was widely distributed for a
review period. The draft was placed on the Monterey County EMS web site and a notice
that it was available for review was sent to:
County Board of Supervisors
Hospital administrators and councils
Ambulance providers ground and air)
Emergency Communications Center PSAP)
Sheriff-Coroner
Fire agencies
Law enforcement agencies
Medical society/Medical groups
A public hearing was held on April 13, 2011 at the Emergency Medical Care Committee
meeting. The Monterey County Trauma Care System Plan was endorsed and forwarded to
the Board of Supervisors for consideration.
On June 14, 2011, the Monterey County Board of Supervisors approved the revised
Trauma Care System Plan and directed submission to the California Emergency Medical
Services Authority. See Attachment H Board Resolution)
Monterey County Trauma Care System Plan Page 18
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X. WRITTEN DOCUMENTATION OF LOCAL APPROVAL
Monterey County Board of Supervisors Resolution approving the revised Trauma Care
System Plan 2011) and directing the submission to the California EMS Authority See
Appendix H Board of Supervisors Resolution)
Monterey County Trauma Care System Plan Page 19
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XI. LOCATIONS OF TITLE 22 REQUIRED INFORMATION
100254 Trauma system criteria Page and Identifier Location
a) System design criteria Page 6 Section IV.B
Projected patient volume and projected
number and level of trauma centers
necessary Page 6 Section IV.B and
Appendix B Trauma System Volume)
Transport times Page 7 Section IV.B
Resource availability Page 8 Section IV.B
Distinct service areas
Coordination with neighboring trauma
systems Page 8 Section IV.B QI & System
Evaluation Policy
d) Pre-hospital provider training Page 8
e) Communication equipment Page 8 and Appendix E Ambulance
Ordinance Excerpt
Hospital notification Page 8 EMS Aircraft Policy
100255 Policy development Pages 9 through 12
100256 Trauma plan development
a) Plan contents Page 2 Section I
1) Summary of the plan Page 2 Section I
2) Organizational structure Page 3 Section II
3) Needs assessment Page 4 Section III and
Appendix B Trauma System Volume)
4) Inclusive system design Page 5 Section IV
5) Inter-county agreements Page 13 Section V and Trauma Mutual
Aid and Coordination Policy
6) Objectives Page 14 Section VI
7) Implementation schedule Page 15 Section VII
8) Fiscal impact of the system Page 16 Section VIII
9) Policy and plan development process Page 17 Section IX
10) Documentation of local approval Page 18 Section X
b) System design
Page 1 and Page 5 Section IV.A
1) Critical care capability
Page 8 Resource Availability"
2) Medical organization and management Page 9 Trauma System Organization
and Management Policy
3) Quality improvement Page 10 Trauma QI and System
Evaluation Policy
100257 Data collection
a) Standardized data collection instrument
and data management system Page 9 Trauma Data Collection and
Management Policy
b) Pre-hospital data elements Page 9 Trauma Data Collection and
Management Policy
c) Hospital data elements Page 9 Trauma Data Collection and
Management Policy
Monterey County Trauma Care System Plan Page 20
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COMPLETED BOARD ORDER"�|E��!�April 2011
XII. APPENDICES
Appendix A California County Map
Appendix B Trauma System Volume
Appendix C Trauma System Resource Assessment
Appendix D Population Density Map of Monterey County
Appendix E Excerpts From Ambulance Ordinance Communications
Appendix F Medical Advisory Committee Membership
Appendix G Notice of Public Hearing
Appendix H Board of Supervisors Resolution
Monterey County Trauma Care System Plan Page 21
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California Map
Monterey County
Appendix A
Monterey County Trauma Care System Plan Page 22
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Trauma System Volume
Projections and 2003 Data
Annual Critical Trauma Patient Volume Estimates:
Based on 2003 population of 421,355)
Estimate of one critical trauma patient per 1,000 population annually
Common over triage rate estimate of 50%
Total patients estimated as trauma victims from Monterey County
Monterey County 2003
Actual Critical Trauma Patient Volume
Total Patients:
Community Hospital of the Monterey Peninsula
Mee Memorial Hospital, King City
Natividad Medical Center, Salinas Note *)
Salinas Valley Memorial Healthcare System, Salinas
Coroners, no transport
Santa Clara County Trauma Centers
Unable to Locate Helicopter Transport Out-of-County
Fresno Trauma Centers
Penetrating trauma:
Pediatric Patients less than 15 years old):
Transports:
Helicopter
Ground
Coroners
Local Hospital Patient:
Died
Penetrating trauma
Note *: Missing data
Appendix B
421
210
631
418
65 15.6%)
2 00.3%)
22 05.2%)
118 28.3%)
80 19.1%)
8 28.3%)
7 1.7%)
6 1.5%)
87 20.8%)
30 7.1%)
116(27.7%)
222(53.1%)
80 19.2%)
207 49.4%)
40 19.3%)
44(21.2%)
Monterey County Trauma Care System Plan Page 23
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Trauma System Resource Assessment
County Population: Note *)
2003: 421,355 estimate)
2010: 453,636 projection)
2020: 505,359 projection)
Note *: State of California, Department of Finance; http://www.dof.ca.aov/)
Resources:
Appendix C
In-County Acute Care Hospitals:
Community Hospital of the Monterey Peninsula, Monterey Basic
Emergency Service
Mee Memorial Hospital, King City Basic Emergency Service
Natividad Medical Center, Salinas Basic Emergency Service
Salinas Valley Memorial Healthcare System, Salinas Basic Emergency
Service
Out-of-County Trauma Centers:
Santa Clara Valley Medical Center, San Jose Level I Trauma Center
Stanford Medical Center, Palo Alto Level I Trauma Center
University Medical Center, Fresno Level I Trauma Center
Regional Medical Center of San Jose Level II Trauma Center
Tertiary Services:
STEMI Center: Salinas Valley Memorial Healthcare System; Community
Hospital of the Monterey Peninsula
Burn, spinal/neuro, peds and reimplantation services in San Francisco
and Santa Clara counties
Ground Transport:
ALS Emergency Transport AMR
Number of ALS units in county 17
Number of ALS units from Santa Cruz County 2 six total with 2 units in
south county)
Number of ALS units from San Benito County 2
Number of BLS units in county 0
Number of CCT units in county 1
ALS Emergency Transport Carmel Regional Fire Ambulance
Number of ALS units in county 1
ALS Emergency Transport-Carmel Valley Fire District
Number of ALS units in county 2
Monterey County Trauma Care System Plan Page 24
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ALS Emergency Transport Fort Hunter Liggett Fire Department
Number of ALS units in county 1
ALS Emergency Transport San Luis Obispo Ambulance
Number of ALS units out of county I
ALS Emergency Transport Cambria Ambulance
Number of BLS units out of county 1
Helicopter Transport Services:
CALSTAR 5 Salinas Airport)
CALSTAR 2 Gilroy)
CALSTAR 1 Hayward)
CALSTAR 7 Santa Maria)
CHP H-70 Paso Robles Airport)
LifeFlight Stanford Medical Center)
Reach Concord)
Skylife Fresno)
Medi-Flight Modesto)
Mercy Air Ambulance Fort Hunter Liggett)
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Appendix D
Population Density Map of Monterey County
Monterey County Trauma Care System Plan
Page 26
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Appendix E
Excerpts from Ambulance Ordinance #5138 Communications
15.40.048 Operational standards and requirements for ambulance and critical
care transport services.
A. Emergency Ambulance Drivers and Attendants. Any emergency ambulance attendant or
emergency ambulance driver utilized by an operator or provider shall be at least
eighteen 18) years of age; shall be trained and competent in the proper use of all
emergency ambulance equipment; shall hold current certification as an Emergency
Medical Technician I-Ambulance EMT-1) or Emergency Medical Technician-P EMT-P);
or be licensed as a physician or registered nurse in the State of California, and shall
demonstrate compliance with all applicable State laws and regulations.
B. Uniform and Appearance. Each person providing emergency ambulance transportation
service subject to this Chapter shall staff each emergency ambulance with appropriate
personnel who shall wear clean uniforms that identify the employer or sponsoring
agency, have visible identification of name and certification level, and comply with the
requirement of this Chapter.
C. Dispatchers. Each person providing emergency ambulance transportation service
subject to this Chapter shall assign at least one 1) person or an agency to be
responsible for receiving calls and dispatching emergency ambulances. Such person or
agency shall be located in Monterey County, unless otherwise specified by contract.
D. Inspection. The emergency ambulance transport operator or provider shall allow the
EMS Agency or its designee to inspect, on an announced or unannounced basis, all
operational areas and equipment used to provide services in the County. The
inspections should be held, whenever possible, during normal business hours; provided,
however, that the inspection of an ambulance will be stopped should the ambulance be
needed to respond to a request for immediate service. The purpose of such inspections
may include, but need not be limited to, determining whether:
1. The emergency ambulance is properly maintained and equipped for the provision of
emergency ambulance service;
2. The emergency ambulance and its equipment comply with the requirements of law
for the level of service provided;
3. The emergency ambulance contains two-way radios; the radios are in good working
order and the radios are compatible with the County's Emergency Medical
Communications and Dispatch System; and
4. If the emergency ambulance is used for critical care transport, the communication
system allows the emergency ambulance driver and emergency ambulance
attendant to communicate with the medical staff at both the discharging and receiving
facilities.
Monterey County Trauma Care System Plan Page 27
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Appendix F
Medical Advisory Committee Membership Expanded
Name
Dr. Michelle Kalinski
Byron Merritt
Vacant
Cindy Banuelos
Dr. Ruth Selvidge
Carlie Vigliotta
Dr. Rakesh Singh
Hal Rightmyer
Scott Houchin
J. Michael Kline
David Wiebe
Cindy Williams
Vacant
Tammera T" Badano
Dr. James Stubblefield
Affiliation
CHOMP Emergency Physician
CHOMP Base Hospital Coordinator
Mee Emergency Physician
Mee Base Hospital Coordinator
Natividad Emergency Physician
Natividad Base Hospital Coordinator
SVMH Emergency Physician
SVMH Base Hospital Coordinator
Fire Chiefs Association
Law Enforcement Chiefs Association
Air Ambulance Provider
EMT and Paramedics
EMT and Paramedics
Primary Ambulance Contractor
EMS Medical Director Chair
Monterey County Trauma Care System Plan Page 28
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COMPLETED BOARD ORDER"�|E�� !�Notice of Public Hearing
Appendix G
MONTEREY COUNTY EMERGENCY MEDICAL CARE COMMITTEE
Meeting Announcement Agenda
Wednesday, April 13, 2011 10:30 a.m.
Monterey County Health Department Whitney Conference Room Room 129 A&B)
1270 Natividad Road, Salinas, CA 93906
The Emergency Medical Care Committee EMCC) is appointed by the Board of
Supervisors to advise the Board and the EMS Director on EMS issues, and to ensure all
EMS constituents will be actively engaged in decisions regarding the use of County
EMS funds and the development of County EMS policies." Monterey County Code Sec.
15.40.030F.
1. CALL TO ORDER
a. Introductions welcome.
b. New EMS Director's Kirk Schmitt) comments/vision.
c. Action: Approval of the 2/8/11 Meeting Minutes See Attachment 1).
2. ORAL COMMUNICATIONS
Any member of the public may address the Committee for a period not to
exceed three minutes on any issue not the Committee's agenda. The EMCC
will listen to all communications but may not take any action.
3. CORRESPONDENCE None
4. PUBLIC COMMENT Monterey County Trauma Care System Plan 2011)
5. REPORTS
a. Report: Emergency Medical Services EMS) Agency
b. Report: Medical Advisory Committee MAC)
c. Report: EMS Operations Committee
6. OLD BUSINESS
a. Report: Update on the CSA74 MOU EMS Equipment and Training
Progress Report; transition of EMS Training; and the AHA CPR Training
Center.
7. NEW BUSINESS
a. Presentation: Staff presentation on the CSA 74 Fund and EMS Agency's
Budget.
Monterey County Trauma Care System Plan Page 29
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COMPLETED BOARD ORDER"�|E��!!�b. Report/Action: Staff will provide a progress report on the revised Monterey
County Trauma Care System Plan 2011) and requests the endorsement
of the EMCC to forward the Plan to Board of Supervisors for
consideration.
c. Presentation: Staff will provide a timeline for the revised ALS Provider
Agreement.
d. Discussion/Action: Staff will provide the proposed format for ambulance
AMR) performance monthly and quarterly reports and requests the
endorsement of the EMCC to implement.
e. Presentation/Action: Staff will request the review and endorsement of the
revised exhibits attachments) to 2010 EMS Plan update to 2009 EMS
Plan).
8. GOOD OF THE ORDER, ANNOUNCEMENTS, AND ADJOURNMENT
a. Announcement: The EMCC will next meet on June 8, 2011 at 10:30 a.m.;
meeting location Health Department's Whitney Conference Room 129
A&B).
b. EMCC elections of Chair and Vice-Chair at the June EMCC.
c. Membership term expirations 6/30/11), nominations and Board
appointments.
d. EMS web page comment/recommendations
e. Adjournment.
Attachments: EMCC Minutes 2/08/11
Monterey County Trauma Care System Plan Page 30
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