CRMC loses level 3 trauma designation

2524594+0B_5W8dpKROTKSFpqXzdhcTktNEE.jpg — Cuyuna Regional Medical Center in Crosby, here in a file photo, is no longer a level 3 trauma designated hospital after the state denied its application for redesignation. Renee Richardson/Brainerd Dispatch

By Renee Richardson

March 04, 2017 at 4:31 PM

NOTE: This story was published on March 4, 2017.

Major trauma victims in critical condition facing a life-threatening injury-perhaps in a home mishap or car crash-can no longer be treated at Cuyuna Regional Medical Center in Crosby unless they arrive by private vehicle.

The medical center's re-application for a level three trauma designation was denied after the State Trauma Advisory Council found CRMC had "ongoing global deficiencies with its performance improvement program dating back to 2007."

"Due to the serious and ongoing nature of the deficiencies," the State Trauma Advisory Council recommended CRMC not be redesignated in the state trauma system. Cuyuna Regional Medical Center had been part of the statewide trauma system from its inception in 2005. Now the 25-bed critical access hospital is no longer a state-designated level three trauma hospital. Non-critical and non-life-threatening injuries may still be served at CRMC. And CRMC is under no obligation to keep or transfer any trauma patient regardless of severity if the patient arrives by private vehicle.

As a result of losing the trauma designation, Minnesota law states the CRMC cannot advertise itself as a trauma center or trauma hospital or otherwise indicate it has trauma treatment capabilities. Ground ambulances are not permitted to transport major trauma patients to CRMC. And other designated hospitals can no longer send or transfer major trauma patients to CRMC, which was required to notify hospitals and emergency medical services providers of its change in status.

The road to that decision began months earlier.

In April of 2016, CRMC submitted an application for re-designation as a level three trauma hospital. Applications for re-designations are required every three years. The process involves an application and supporting documents followed by a site visit where a three-member team from about 20 site reviewers in the state visits the medical center. The site visit at CRMC occurred May 26. Two months later a State Trauma Advisory Council Review report raised concerns.

"Substantial changes to the trauma program at CRMC are necessary for the hospital to meet the essential criteria of the statewide trauma system," the July report stated. "It is important that the hospital commit to and maintain the trauma system resource requirements in order to provide optimal trauma services to the community and region."

On Sept. 13, 2016, the State Trauma Advisory Council met and among other agenda items considered the re-designation for CRMC.

"Considered collectively, these issues illustrate a global deficiency of a functional performance improvement (PI) process. After thoughtful discussions and careful review of the findings, the Application Review Committee believes that, given the apparent lack of leadership, understanding and infrastructure, it is unlikely that the hospital will remedy these deficiencies if granted an extension and unanimously recommends that Cuyuna Medical Center not be recommended for re-designation."

The State Trauma Advisory Council discussed the matter, agreed with the recommendation and voted unanimously to send that recommendation to Dr. Edward Ehlinger, the state's commissioner of health.

"In the time between May and September there was just not a recognition and commitment to specifically address the issues that were called out," said Tim Held, deputy director/unit supervisor with the Office of Rural Health and Primary Care, in a telephone interview. "And this is the first time in the history of the system that a hospital was not re-designated. ... This is the first time where we've had an applicant come through and have it denied."

Held said the deficiencies in this particular case were all around that performance improvement process, the case review, identifying issues and ways to improve and involving others, particularly surgeons, in the process.

"The engagement with surgeons wasn't what was felt to be up to par for standards," Held said.

He said it doesn't happen often but when there have been deficiencies ongoing with staff, the State Trauma Advisory Council works with hospitals, if they are committed at the highest levels to fix something, and that has happened in a handful of cases since the program began.

On Sept. 22, 2016, CRMC sent a letter to the health commissioner signed by trauma service physicians and the hospital administration. The letter stated CRMC has been dedicated to excellence in rural trauma care for 30 years, well in advance of the birth of the statewide trauma system. The current requirements for the level three designation "as evaluated and implemented by the Department of Health and the State Trauma Advisory Council do not adequately respect nor fully understand the widely varying needs and capabilities of Minnesota's many small, rural hospitals, including Cuyuna Regional Medical Center," the letter stated. It was signed by Kyle Bauer, interim CEO, Dr. Paul Allegra, Dr. Howard McCollister, Dr. Paul Severson, Dr. Tim LeMieur, Dr. Shawn Roberts, Dr. Erik Severson, Dr. Susan Moen, Dr. John Herseth and Dr. Rob Westin. The letter served as notification of CRMC's resignation from the statewide designation.

"We are firm advocates of and strong believers in quality rural health care, and we have been long-recognized leaders in that arena, both on a state and national level," the letter stated. "We firmly believe in the critical importance of quality trauma care in rural America and our record and reputation over three decades clearly supports that assertion."

The letter informed the state the intent was to continue to provide the same trauma services and robust innovative trauma program development CRMC has always provided.

"Hospitals that do not participate in the trauma system cannot receive (major) trauma patients unless there is no designated trauma hospital within 30 minutes (by ground ambulance) of the scene," the state health department reported. Since 2010, ambulance services are required to comply with the 30-minute rule. Patients transported by air ambulance are taken directly to level one or level two hospitals for treatment.

On Oct. 13, 2016, the state health commissioner sent a reply recounting the months of deliberation on this matter and the recommendation by the State Trauma Advisory Council to deny the re-designation. "Subsequent to that action, CRMC sent a letter of resignation dated Sept. 22," Ehlinger wrote. "However, there is no provision in statute that permits a voluntary withdraw from the system absent a formal refusal of designation. Therefore, according to STACs recommendation and in acknowledgement of your requested resignation, I am denying your application for redesignation."

"Trauma system hospital designations assure the public and EMS providers that standardized trauma education, policies, and clinical quality review processes are verified and integrated into the care of seriously injured patients, so that patients receive the most accountable and timely quality care," Ehlinger wrote. "Designations also recognize that both the administrative and medical leadership are committed to meeting all required designation criteria. Participation in the statewide network of dedicated trauma hospitals is a valuable community asset.

"I encourage CRMC to consider the industry-proven patient and provider benefits of a trauma performance improvement process, and to integrate this into its existing trauma care model. I have instructed my staff to contact you within the week to offer any assistance you might desire should you want to reapply for trauma designation in the future."

--- --- --- --- ---

Report and Letters

Click to View - Cuyuna Regional Medical Center Trauma Hospital Site Visit Report - July 26, 2016

Click to View - Cuyuna Regional Medical Center Level 3 Trauma Hospital Designation Resignation - Sept. 22, 2016

Click to View - Minnesota Department of Health Denial of Level 3 Trauma Hospital Application - Oct. 13, 2016

--- --- --- --- ---

Cuyuna Regional Medical Center hasn't contacted the state or pursued a new request for redesignation, but the state did reach out and a meeting was scheduled Feb. 24 only to be canceled after the forecast called for blizzard conditions in the southern part of the state and more than a foot of snow in the Twin Cities. A new meeting is now scheduled in April.

Peggy Stebbins, CRMC spokeswoman, said CRMC views a meeting with representatives of the State Trauma Advisory Council as a positive step to get CRMC's input on how the medical center sees optimal trauma care being delivered in its facility.

Stebbins wrote in an email that whether CRMC decides to re-apply will be based on whether the advisory council's review processes are aligned with CRMC's goals of providing the best care for its patients. Additional comments were sought from CRMC regarding how its views differ from the state but were not available. Stebbins said those topics are ones CRMC looks forward to discussing with the State Trauma Advisory Council.

For Minnesotans, ages 1 to 44, trauma is the leading cause of death, the state health department reported, adding, overall, trauma is the fourth leading cause of death for Minnesotans.

The health department said states with a mature, comprehensive statewide trauma system have experienced:

• A 9 percent decrease in motor vehicle crash deaths.

• A 15-20 percent increase in the survival rates of seriously injured patients.

• An increase in productive working years.

• An improvement in disaster preparedness.

"We would love and want Cuyuna back in the system the whole system is stronger when everybody is part of it," Held said. "That is absolutely by far our desire. We'll do whatever we can do to help provide technical assistance whatever we can do on our end to help and we would do that but the bottom line is you have to meet criteria. We just think the system is stronger and we think the communities are better served when everybody is working together in these standards of care that are known to improve patient care and patient outcomes."

Strengths, deficiencies, opportunities for improvement

To give an idea of participation in the statewide trauma system, more than 100 hospitals in the state are part of it and about a handful are not. Held said there is a small reimbursement CRMC loses without the trauma designation that is used to offset the cost of mobilizing the hospital's trauma team but it doesn't play a significant role in a hospital's budget.

The state's site visit report pointed to many strengths for CRMC, describing the emergency medical service program as outstanding. Staff in the emergency department were described as well trained and working in spacious rooms and rendering thorough care. The lab department and orthopedic service were also praised.

However, dischord was evident to the state team within 10 minutes of the arrival for the site visit.

"Unfortunately, the transition period for the two key leadership roles has been to the detriment of the trauma program," the site report stated, noting the key roles of the trauma medical director and trauma program manager. Dr. Paul Allegra was new to the trauma medical director's role since the last site visit. The outgoing trauma program manager, Violet Mussell, was noted as being active in the Minnesota Regional Trauma Advisory Committee. "It was evident within 10 minutes of the introductory comments that there was not a collaborative relationship between the outgoing (trauma program manager) and the current (trauma medical doctor)."

The medical campus in Crosby includes the 25-bed hospital with an average daily census of about 15 patients, Minnesota Institute for Minimally Invasive Surgery and Minnesota Center for Orthopedics and Minnesota Center for Obstetrics and Gynecology. The hospital has its own ambulance service. Cuyuna Regional Medical Center expanded its emergency department from six to 14 beds in 2016 and sees about 10,500 patients there annually with five surgeons providing trauma call coverage.

The site visit report listed deficiencies in the limited involvement by the trauma medical director in the performance improvement process and a limited understanding of his role.

"There is no evidence that the trauma medical director and trauma program manager, along with other key players of the team involved in trauma care, are conducting critical case reviews," the site report stated. "There has been only cursory review of trauma care over the past two years."

The report noted there is no evidence providers attended 50 percent of the meetings as required and while there were components of one, there is essentially no functional performance improvement process with little or no evidence surgeons participate in the trauma program or the care of trauma patients.

"General surgeons should assume a leadership role in the level three trauma hospital and provide clinical oversight of trauma care via the performance improvement process," the site review report stated. "They should aspire to meet the needs of trauma patients in the community and region by accepting the responsibility of caring for trauma patients admitted to the facility." The report also listed specific opportunities for improvement, including ways to reduce time a trauma patient stays in the emergency room before being transferred, noting trauma patients have the occasional tendency to harbor life-threatening occult injuries and can deteriorate after at first appearing stable.

"Trauma system hospital designations assure the public and EMS providers that standardized trauma education, policies, and clinical quality review processes are verified and integrated into the care of seriously injured patients, so that patients receive the most accountable and timely quality care," Chris Ballard, trauma system coordinator, wrote in a letter to CRMC in October. "Designations also recognize that both the administrative and medical leadership are committed to meeting all required designation criteria. Participation in the statewide network of dedicated trauma hospitals is a valuable community asset.

The site review summary

An eight-page site visit review included this summary. The quality improvement process is called a performance improvement or PI within the trauma system.

• Previous site visits identified insufficient surgeon involvement in clinical care and (performance improvement) activities. This continues to be a problem.

• The (performance improvement) process is ineffective. The program has had two marginal PI meetings in the past two years and none within the last year. The friction between the (trauma program manager) and (trauma medical director) appears to be hindering the performance improvement process. The (trauma medical doctor Dr. Paul Allegra) could benefit from better understanding trauma performance improvement and the multidisciplinary approach to programmatic PI.

• Substantial changes to the trauma program at CRMC are necessary for the hospital to meet the essential criteria of the statewide trauma system. It is important that the hospital commit to and maintain the trauma system resource requirements in order to provide optimal trauma services the community and region.

State Trauma Advisory Council

In 2005, the Minnesota Legislature established a statewide trauma system and charged the Department of Health with implementation. Participation is voluntary. Medical centers reapply for designation every three years. After an application answering questions and providing supportive documents is reviewed and completed, the next step is to schedule a site visit. It can take several months to set up. The site review team typically involves a trauma surgeon, a trauma program manager (usually a nurse manager) and a state staffer who spend about six hours at the facility. The team meets with staff, ask questions and tours the facility. The site visit is used to verify what the medical center describes on paper to see if staff is following those protocols in actual practice. Part of the review is going through case reviews to evaluate care given.

"For a severely injured person, the time between sustaining an injury and receiving definitive care is the most important predictor of survival-the 'golden hour,' the state health department reported. "The chance of survival diminishes with time, despite of the availability of resources and modern technology; however, a trauma system enhances the chance of survival regardless of proximity to an urban trauma center.

"A trauma system is a pre-determined and organized response to managing and improving the care of severely injured people. It spans the continuum-of-care; from prevention and emergency care to rehabilitation. Best practices standards guide each stage of trauma care to ensure that injured people are promptly transported to and treated at facilities appropriate to the severity of their injury."

Go to www.brainerddispatch.com to read the full site visit report and corresponding letters.

Held, deputy director/unit supervisor with the Office of Rural Health and Primary Care, said a lot of the site review is spent trying to understand how the medical facility is implementing its quality improvement process.

"How are you going to fix something if you don't know it's broken," Held said.

NOTE: This clarifcation was added to the story to note CRMC is under no obligation to keep or transfer any trauma patient regardless of severity if the patient arrives by private vehicle.

--- --- --- --- ---

Area hospitals and trauma designations

In 2005 the Minnesota Legislature established a statewide trauma system and charged the Department of Health with implementation.

Here are the area hospital designations and those of hospitals often used when patients transfer out of the lakes area.

Level 1 (four medical centers)