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  • Lean practices and starting a trauma center.

    Posted by Michael Kennedy on May 19th, 2010 (All posts by )

    The discussion of the pharmacy reorganization got me thinking of the trauma center that we started in 1979. That was well before I learned about lean practices or the Toyota method but I think we used a number of their principles anyway.

    When we started our trauma center, we did something a bit like your pharmacy project. We were a small hospital (120 beds) in a new suburban area with the ocean on one side and national parks and mountains on the other. Orange County narrows down to a triangle which ends at San Clemente where the Marine base begins. We knew the county was going to regionalize trauma. A study had come out suggesting that too many people died because “the golden hour” was lost in trying to get doctors and operating rooms organized, especially at night.

    Several large hospitals planned to enter a competition to qualify as centers; one of course, was the UCI medical center. None of them was within 25 miles of our hospital. We didn’t like the idea of seeing the injured patients, some of whom would be neighbors, being taken that far and we looked to see if we could set up a trauma center for our community that would pass muster with the EMS survey team. First we had to see if the hospital and medical staff would support it. My partner and I couldn’t do it alone.

    I did a study of the finances of trauma. The stereotype is a drunken insolvent who is stabbed or shot. Our community is located along I-5 where it runs from Los Angeles to San Diego. We are between mountains and the sea. I took the records of all emergency admissions, who went to surgery or who were discharged with a “surgical” diagnosis and who went to ICU. Some of those were general surgery but by using a screen we got down to the trauma cases. I found that 85% of them had some sort of insurance. This was largely because most were auto accidents. Even if people don’t carry health insurance, somebody may have medical benefits with car insurance.

    We presented this to the department of surgery and they turned us down flat. The vote was something like 33 to 2. We went to the Board of Trustees. At the time, the hospital was owned by a partnership, one of the dreaded for-profit hospitals. The Board was easily convinced that this was something we needed to do if this hospital was going to grow. Southern California is cursed with many small hospitals and few big ones outside of Los Angeles. I knew a vascular surgery group, of three men, in the San Fernando Valley that went to 12 hospitals. One of the reasons I moved to Mission Viejo was to get out of Los Angeles.

    Anyway, we had the hospital on board but not the doctors. The hospital decided to make the trauma center a contract service like the ER. My partner and I would run it. The hospital hired a city planner to draw up a proposal for the county. They gave me a copy when he was finished and it was the size of a Chicago telephone book. I read through it and it sounded like a proposal for a shopping center. I rewrote it. A lot of it was useful, like traffic analysis, but the vast majority didn’t answer the right questions.

    Then we had to figure how we could do this and not go broke. There were two of us. We would call other specialists, like orthopedists and neurosurgeons, as needed. That’s how we got around the surgery department. There were grumbles but they faded as the orthopods began to realize that trauma cases paid well, mostly. Then we figured out who is in the hospital at night. The other trauma center candidates all promised to have a surgeon and anesthesiologist in-house 24 hours per day. We could not afford that. We promised that the surgeon and anesthesiologist would arrive within 15 minutes of being called, usually before the victim. The ER doc would be there. That was just as Emergency Medicine was becoming a specialty and our ER docs were GPs.

    Hospitals staff ICUs and operating rooms based on need and having someone sit around all night was not in the plan. One night, I was out for dinner with my wife, who was a part time ICU nurse, and I was called for a patient with a ruptured aneurysm. There was no time to take her home so we went to the hospital and I told her to put on greens and come into the OR with me. She worked in another hospital and there was a bit of complaining later by the usual bureaucrats but we got a live patient to go home so not much was said. I had her help the anesthesiologist by pumping blood and getting drugs for him. Later, I thought about this and we devised the “trauma nurse.”

    I asked for volunteers. The nurse had to be ER or ICU trained and would then have to be cross trained in all three places, ER, ICU and OR. They would be paid to be on call and had to agree to get to the hospital in 15 minutes when called. We were deluged with volunteers.

    The next member of the team was the pharmacist. Our hospital had a 24 hour pharmacy and we asked the pharmacists if they would like to be part of the trauma team. Would they ! So we had another member. The final team member was the night supervisor who would be responsible for calling people, rescheduling people the next morning if we were going to bump somebody’s 7:30 case, and helping with anything that needed doing. Again, we had enthusiastic volunteers although it was going to be more work.

    Once we had the team, we worked out scenarios. What kind of cases would we get ? We settled on three likely scenarios. Head trauma that is stable otherwise. Head trauma that is unstable and has other serious injuries. And non-head trauma.

    The hospital in those days was all on one floor, so that part was easy. The CT scanner (No MRI yet) was across the hall from the ER. The ER was often full of “worried well” and we needed our own space so we got a “Trauma Room.” It was a treatment room that has oxygen and suction and enough room for all the people who would be there. Now it is a wing but that was 30 years ago. Just outside the ER ambulance entrance was the helipad and the trauma room was right inside the entrance. Once I had three helicopters circling the hospital. Fortunately, those days were rare.

    We then choreographed the trauma room. The bed was positioned in the middle with the treatment team arranged in a certain way around it. At the head stood the anesthesiologist. He was responsible for the airway, including intubating the patient if needed. In head cases, the neurosurgeon stood next to him. The trauma surgeon stood at the patient’s abdomen. He/she could examine the patient, especially chest and abdomen and, if necessary place a tube into the abdomen to look for blood. At the feet stood the ER doc. He could check the legs for fractures and do a cutdown on an ankle vein if the patient was really in shock. He was out of everybody else’s way there. The trauma nurse stood back and recorded as the three physicians dictated their findings. The pharmacist handled all meds and fluids. Everybody had a spot that was out of the others way.

    Our three scenarios came next. The very first move was a lateral cervical spine x-ray to see if we had a broken neck. I have had two patients come in with beating hearts and blood pressure who, on the lateral x-ray had been decapitated. There was an inch or more between the first and third vertebra. Only the skin held the head on. If the patient was stable and had a head injury, we went to CAT scan across the hall. From there, the neurosurgeon took over. If there was a broken bone, the orthopod would get called. The trauma surgeon would hang around long enough to be sure all was well otherwise. We were the ones responsible for the admission and controlled post-op care unless the neurosurgeon did.

    Fortunately, we had two terrific neurosurgeons who were brothers. When the younger brother arrived, I saw the letter from Johns Hopkins telling us how sorry they were to lose him. They were in the absolute forefront of the care of head injuries and we began to get survivors who would have died a year before, which posed some interesting issues in rehabilitation. That is another story.

    If the patient was unstable with a head injury, we would take him through the CAT scan for three “cuts” of the brain and then straight to OR. Once the patient was safely alive and stabilized, we would go back for a full CAT scan. Sometimes we would have three operations going on at a time with the neurosurgeon opening the head next to me as I opened the belly and the orthopod irrigated compound fractures on my right. Usually we used some triage but you couldn’t always.

    Behind us and next to the anesthesiologist stood the doughty trauma nurse. The theory was that she (There were no “hes” when I was running it but there may be now.) would accept the patient as hers in the ER as he arrived. She recorded all that was done. In the ER, the pharmacist did a lot of what nurses usually do with drugs and she recorded it all. If it got too hectic, we threw all the bottles and bags from fluid and blood along the wall where they would be counted later.

    When the patient went to CAT scan the trauma nurse went with him. If he was stable, she was the only one there as the others would be in the control room. When he went to the OR, she went too and helped with blood and fluids and kept recording what happened. When the surgery (ies) were over and the patient was stable and went to ICU, the trauma nurse would report to the ICU nurse. At that point she was done and was off. Some of those cases went 24 hours and more. The trauma nurses mostly stuck it out as they were very proud of their role.

    That was 30 years ago. The first few years, we would get a trauma every two days or so. Today, they get about five a day. Some of them are helicoptered in from the barrios of Santa Ana so they see a lot more stab and gun shot wounds now. We were all trained at LA County or UCI, both of which have large trauma services so there was no great learning curve except how to work in the system we set up and that was pretty intuitive.

    The concept has spread all over the world and there were shock/trauma units at places like the U of Maryland before we began. This, however, was the first geographically organized trauma system, I believe, in the world.

    When the survey team visited the hospitals, I believe there were 24 applicants, they ranked little Mission Hospital’s team #2 and we were told they felt obliged to rate the university hospital #1 for political reasons. Over the years, the volume grew and about ten years after we began, there was a push in the legislature to write formal regulations into the law. Donald Trunkey, whose concept this all was and who was by then Chairman of Surgery at Oregon, was there as the Assembly committee’s expert. They wanted to write a regulation that a trauma center had to have an in-house surgeon and anesthesiologist, just as the original concept had required until we got an exemption because of the distance from other hospitals. I testified against the regulation, citing our own experience. Don Trunkey got up and said, “I don’t know how you and Shaver have done this but I’ll go along with the exception. Nobody else could do this.” Mission Hospital now has in-house anesthesia, mostly for OB epidurals. There are no in-house surgeons although it seems that way sometimes and it has been the top ranked trauma center in California for years.

     

    5 Responses to “Lean practices and starting a trauma center.”

    1. Jonathan Says:

      A wonderful story, Michael. Thanks for sharing.

    2. onparkstreet Says:

      Interesting, indeed.

      MK: as a surgeon, what do you think pathologists could be doing differently? I am not talking about the typical TAT (turn around time) issues which always vex, but if YOU as a surgeon could build the department, how would you do it?

      – Madhu

    3. Michael Kennedy Says:

      There are lots of little details but I certainly wouldn’t try to deal with a whole department. First of all, I don’t know how your workflow goes. How many times do you walk back and forth to and from one spot. That sort of thing.

      We actually had a problem with surgical specimens getting lost. It happened to me twice and one of those times was the axillary specimen from a young woman with breast cancer. It turned out that the system hadn’t been looked at in years and had developed, as these things do, by accident. The immediate response from the OR supervisor was to punish the two nurses in the room. “The floggings will continue until…”

      We actually traced it to the interface between OR and lab. There was no good system of logging times and who did what. Of course, this put the pathology department into a defensive crouch.

      Paul Bataldan, who runs, or ran, the quality analysis shop at Dartmouth had a saying, “Every system is perfectly designed to get the results it gets.”

    4. onparkstreet Says:

      Oy, tell me about it.

      I walk around a lot – in private labs the pathologist doesn’t do that much because the group wants to keep the “eyeballs on the scope.” In teaching hospitals, a central administrator may try to keep costs down by cutting ancillary staff, which means the docs end up doing the ancillary work, like answering non-physician phone calls (things that don’t require physician input) and looking up their own old reports and slides. TAT increase and fewer cases (billable cases) are seen per day.

      I’m gonna do a little study based on what you’ve written.

      – Madhu

      (My question was kind of rhetorical, too. I’ve said what I thought would improve things in other hospitals I’ve worked at, had good responses, and then nothing happens. Nothing ever happens. One hospital administrator arbitrarily and unilaterally changed our pathology requisitions – specially designed for my specialty by my colleagues and I to facilitate better care – because “the reqs should all look the same.” I am not making this up.)

    5. Michael Kennedy Says:

      As I’m sure you know, administrators are the enemy. The lay public thinks it’s disease but we know better. They, of course, reciprocate with bells on.

      I took a lean course in Nashville a couple of years ago. I was working at the time with a group that had done industrial CQI coaching and wanted to get into healthcare. I was recommended and I spent a few months with them until they realized that they didn’t know squat about health care.

      Anyway, we were all at this meeting in a hotel in Nashville. It became lunch time. Everybody started getting up to go to lunch. I got up and picked up my laptop to take it with me. A couple said “Oh, that’s OK. They lock the doors at lunch. It’s safe.” I took it with me quietly. We came back after lunch and the laptops were gone. One fellow who, I think, had double PhDs and was the resident wizard for somebody, started tearing his hair out and told us he didn’t have anything on his missing laptop backed up !

      Well, I quietly drifted away from that bunch. Doctors and airplane pilots probably have the deepest respect for the bad things that can happen. The surgeon who I first started in practice with, before I moved to Orange County, used to say, “Show me an optimistic surgeon and I’ll show you a surgeon with a lot of complications.”