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Physician - Beloit Ray Georgen, M.D. - State Trauma Advisory Council Member & Trauma Surgeon - Theda Clark ,MA zDWhat is a Trauma System?An organized system of health care delivery that combines out-of hospital care and hospital resources to optimize injury care. Includes the continuum of care: Prevention, Detection, Definitive Care and Rehabilitation. $OGoals of a Trauma SystemThe goal is to match the resources of trauma care to the needs of injured patients resulting in optimal care. The ultimate goal is to decrease suffering, death & disability.8n$@$$9-'WI Trauma System - How did we get here?(') 1990 National Highway & Traffic Safety Administration (NHTSA) Report resulted in: A legislative study committee convening and the passage of Wisconsin Acts 16 & 251 in 1993 - directing DHFS & EMS Board to write 10 reports including: Make recommendations on the need for a WI Trauma System. In response to the 1996 Trauma Report, WI Act 154 was passed. 1997 WI Act 154 - directed DHFS and State Trauma Advisory Council (STAC) to prepare a joint report on the planning and implementation of a Statewide Trauma Care System Plan for Wisconsin. !Q8  >/>Development of Wisconsin s Plan" (WI 1997 Act 154 created the State Trauma Advisory Council (STAC) and required a Trauma Plan by January 2000 and implementation by July 2001. Those dates were later pushed back a year. The State Trauma Advisory Council (STAC) has been meeting since February 2000. Wisconsin s Trauma Plan was developed by STAC by using other State models and by specific tasks via 5 Subcommittees. *~E4"WI Trauma System -Recent History *# (n January, 2001 - Statewide Trauma Care System Plan was submitted to Joint Finance Committee. Request back to DHFS to submit to full legislature thru a legislative sponsor. (Rep. Johnsrud & Sen. Robson) July 2001 - Partial funding bill submitted and passed by full legislature. Partial funding proposal was vetoed in final version of 2001-2002 biennial budget. |ZZZZZ  G5%WI Trauma System - Where are we now? &%  2001-2002 Budget Language STAC s extension until 2003 Confidentiality language for CQI review Hospital classification review changed from every 4 years to every 3 years - ACS standard Coalitions working on funding issues - $1.00 on all licensed vehicles is favored. UU  L,Where s the Money !!!!VGovernor s Reform Budget $398,000 from GPR + Bioterrorism Grant Johnsrud /Robson Trauma Bill Use DOT SEG Funds ($500,000) Passed the House & Senate Now in Joint Finance`(L(LBb12001 Trauma Report: Sub-Committee Recommendations215 Sub-committees: Classification & Verification Out-Of-Hospital Care Issues Education & Injury Prevention Trauma Registry Evaluation@s$$  Classification & Verification ,0 All "Inclusive" System - every hospital would participate. Method to classify hospital emergency capabilities (resources & Personnel). Levels I, II, III, and IV. Level I & II - Use ACS to verify. Level III & IV - Self-classification utilizing State checklist.F  Education & Injury Prevention , 0 Educate 3 P's: 1) population 2) providers and 3) policymakers. Initial trauma training and education "packet" prior to implementation. Coordinate injury prevention and trauma education statewide. Regionally focused (differing needs in education & prevention strategies).v@G Out-of-Hospital Care Issues ,0 Access to Care - Mandatory 911 coverage. Dispatch and Communicators - Education & Training. Field Triage and Transport Guidelines - State minimal standards & protocols Interfacility Guidelines. T Trauma Registry ,0Accurate and reliable information on injuries from a statewide perspective is a necessary foundation to guide trauma system performance improvement and injury prevention activities. Mandatory & systematic data collection can identify trends and lead to new interventions. Phased in for Levels III and IV Trauma Centers. DHFS - will develop, implement and maintain the State Trauma Registry. j  "Evaluation and Quality Improvement## Requires Regional coordination and a statewide Injury Registry. Formation of Regional Trauma Advisory Councils (RTAC). Use Level I and Level II Trauma Centers as Coordinators. Evaluation includes Statewide Trauma System; Regional Trauma Systems & Trauma Facilities. d@ E)Regional Trauma Advisory Councils (RTACs)"*)(KMentioned in each subcommittee report as a Key ingredient Concept: regional/local involvement will make for the most successful system State & STAC role - oversight & coordinating body; RTAC role - adapt the trauma system to meet regional needs RTAC creation by self selection and natural patient flow - currently being formalized8L+MWhat is an RTAC?QAn organized group of healthcare and public safety entities and other concerned individuals who have an interest in organizing and improving trauma care within a specified region. Unifying foundation to bring together all local/regional, state, federal and other agencies for planning, implementing & evaluating injury care in Wisconsin. RRNFunctions of an RTACDevelopment of local/regional protocols Performance Improvement Data Analysis Creation of Community-based Injury Prevention Programs Education of the Public, Policy Makers and Providers Improve communications 7,Trauma System Benefits in WI7845 Years of Productive Life Saved. Based on 15% reduction in trauma deaths. This figure would be much higher if it included years saved due to decreased recovery and disability time for survivors. $64,288,000 saved (64 lives) from associated loss due to economic costs of MV crash deaths alone. Based on National Safety Council estimates on costs for death only. Total economic cost for all injuries is estimated higher than the cost of deaths.'c$`6+Trauma System Benefits in WI406 lives saved - WI total Based on 15% in all trauma deaths (2708 in 1998). 64 Lives Saved from Motor vehicle crashes Based on 9% reduction in motor vehicle crash deaths (9% of 1998 total of MV crash deaths = >700) 8-b '`5*QCauses of Death in Wisconsin Ages 1-44, 1998 (Data from CDC NCIPC WISQARS System)0R-$$$ * `<NYrs. Of Productive Life Lost - WI - 1998 (Data from CDC NCIPC WISQARS System)0O* $ ! YPLL = 65-age at death Tt@7How Will a Trauma System Make a Difference?- 1 Scenario88}A car crash in a rural area with chest trauma: At the crash site (Prevention): Trauma System data decreases severity of injury or prevents crash from occurring At 911 dispatch Medically trained dispatchers: pre-arrival instructions + request appropriate resources First Responders First responders are integrated with the EMS system, are certified and can place an advanced airway/ QXd. QX  cuA,How Will a Trauma System Make a Difference? -,KAmbulance Service Regional protocols result in consistent triage, treatment and transport to the appropriate facility Advance Life Support Paramedic or air medical transport protocols are activated when appropriate Destination Hospital Verified hospital capabilities are known in the region & the patient is transported accordinglydL`dL`  vB+How Will a Trauma System Make a Difference?,,YReceiving Hospital Patient is assessed & either treated or transferred in a timely manner Level 1 or 2 Trauma Center Patient is treated & then transferred to the community hospital once intensive care is complete Interfacility Transfers Patients transferred between facilities receive care using established guidelines based on patient conditionZGZZ`ZZmZG`m  wC+How Will a Trauma System Make a Difference?,,>Rehabilitation Rehabilitation begins early and continues when patient returns to their local community Quality Improvement program Regional review leads to regional improvement Prevention & Education Injury programs target specific local issues and focus program efforts to areas where they can make a difference X.rW.rQBWisconsin Trauma Care System Plan (can be found at web site below)CB(P QUESTIONS??   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T3f3f@&  \j( w \r \ S PYx   Y  \ S \s4x<$D  0 Y &x d<H \ 0޽h ? ̙33$$___PPT10#.+uw*D#' = @B DA#' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\D' =1:Bvisible*o3>+B#style.visibility<*\%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\0D' =1:Bvisible*o3>+B#style.visibility<*\0%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\0D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\0D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\0LD' =1:Bvisible*o3>+B#style.visibility<*\0L%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\0LD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\0LD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\LjD' =1:Bvisible*o3>+B#style.visibility<*\Lj%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\LjD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\LjD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\jzD' =1:Bvisible*o3>+B#style.visibility<*\jz%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\jzD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\jzD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*\zD' =1:Bvisible*o3>+B#style.visibility<*\z%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*\zD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*\z+8+0+\4 +p   DZ(  Dr D S 4x   4  D C \[YxPp<$D  0 4  H D 0޽h ? ̙33NF___PPT10&.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D<D' =1:Bvisible*o3>+B#style.visibility<*D<%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D<D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D<D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D<D' =1:Bvisible*o3>+B#style.visibility<*D<%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D<D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D<D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*DD' =1:Bvisible*o3>+B#style.visibility<*D%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*DD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*DD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*DD' =1:Bvisible*o3>+B#style.visibility<*D%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*DD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*DD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*DD' =1:Bvisible*o3>+B#style.visibility<*D%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*DD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D+8+0+D4 +  L^(  Lr L S Ծ4x   4  L C 4xPp<$D  0 4  ` <8H L 0޽h ? ̙33___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LBD' =1:Bvisible*o3>+B#style.visibility<*LB%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LBD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*LBD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LBD' =1:Bvisible*o3>+B#style.visibility<*LB%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LBD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*LBD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LD' =1:Bvisible*o3>+B#style.visibility<*L%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*LD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LD' =1:Bvisible*o3>+B#style.visibility<*L%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L+8+0+L4 +  H\(  Hr H S  Yx   4  H C d4x<$D  0 Y  ``8H H 0޽h ? ̙33___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*H*D' =1:Bvisible*o3>+B#style.visibility<*H*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*H*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*H*D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*H*]D' =1:Bvisible*o3>+B#style.visibility<*H*]%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*H*]D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*H*]D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*H]D' =1:Bvisible*o3>+B#style.visibility<*H]%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*H]D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*H]D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*HD' =1:Bvisible*o3>+B#style.visibility<*H%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*HD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*H+8+0+H4 +  P^(  Pr P S 4x   4  P C  4x0P <$D  0 4  ` <H P 0޽h ? ̙33___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PD' =1:Bvisible*o3>+B#style.visibility<*P%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PD' =1:Bvisible*o3>+B#style.visibility<*P%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PAD' =1:Bvisible*o3>+B#style.visibility<*PA%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PAD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PAD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PAD' =1:Bvisible*o3>+B#style.visibility<*PA%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PAD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PA+8+0+P4 +  T^(  Tr T S 4x   4  T C BxPp<$D  0 4  ` `8H T 0޽h ? ̙33___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*T@D' =1:Bvisible*o3>+B#style.visibility<*T@%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*T@D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*T@D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*T@wD' =1:Bvisible*o3>+B#style.visibility<*T@w%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*T@wD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*T@wD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TwD' =1:Bvisible*o3>+B#style.visibility<*Tw%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TwD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TwD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*T D' =1:Bvisible*o3>+B#style.visibility<*T %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*T D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*T +8+0+TB +   tD( w tl t C \Bx   B  t C XBx<$  0 B H t 0޽h ? T3f3f___PPT10f.+LD' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*t:D' =1:Bvisible*o3>+B#style.visibility<*t:%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*t:D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*t:D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*t:D' =1:Bvisible*o3>+B#style.visibility<*t:%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*t:D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*t:D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*tD' =1:Bvisible*o3>+B#style.visibility<*t%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*tD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*tD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*tLD' =1:Bvisible*o3>+B#style.visibility<*tL%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*tLD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*tL+8+0+tB +&  0P(  r  S (Bx   B   S )Bx<$  0 B H  0޽h ? T3f3f  ___PPT10 .+LD ' = @B DA ' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*RD' =1:Bvisible*o3>+B#style.visibility<*R%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*RD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*R+8+0+B +&&  @P(  r  S H:Bx   B   S 0;Bx<$  0 B H  0޽h ? T3f3f$$___PPT10#.+LD#' = @B DA#' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*(D' =1:Bvisible*o3>+B#style.visibility<*(%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*(D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*(D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*(@D' =1:Bvisible*o3>+B#style.visibility<*(@%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*(@D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*(@D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*@ND' =1:Bvisible*o3>+B#style.visibility<*@N%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*@ND' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*@ND' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*ND' =1:Bvisible*o3>+B#style.visibility<*N%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*ND' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*ND' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*+8+0+B +  PP(   r  S MBx   B   S NBx<$D  0 B H  0޽h ? T3f3f___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*'D' =1:Bvisible*o3>+B#style.visibility<*'%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*'D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*'D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*'D' =1:Bvisible*o3>+B#style.visibility<*'%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*'D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*'D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*.D' =1:Bvisible*o3>+B#style.visibility<*.%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*.D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*.D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*.D' =1:Bvisible*o3>+B#style.visibility<*.%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*.D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*.+8+0+B +  `P(  r  S ^Bxp  B   S TYx`<$D  0 B H  0޽h ? ̙33___PPT10f.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TD' =1:Bvisible*o3>+B#style.visibility<*T%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*VD' =1:Bvisible*o3>+B#style.visibility<*V%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*VD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*VD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*+8+0+B +   F>p(  x  c $iBx   B   S nBxPp<$D  0 B x  <A R??@ RH  0޽h ? ̙33xp___PPT10P.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D2' =K@BBBBPB0B%(/%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*+8+0+B +   F>8(  8x 8 c $`Bx   B  8 S HBxPp<$D  0 B x 8 <A ??p H 8 0޽h ? ̙33NF___PPT10&.+uw*D' = @B D' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*8D' =1:Bvisible*o3>+B#style.visibility<*8%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*8D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*8+8+0+8Y ++  LP(  Lr L S ĒBx   B  L S Bx<$  0 B H L 0޽h ? T3f3f))___PPT10).+LDF)' = @B D)' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*L/D' =1:Bvisible*o3>+B#style.visibility<*L/%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*L/D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L/D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*L/OD' =1:Bvisible*o3>+B#style.visibility<*L/O%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*L/OD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L/OD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LOD' =1:Bvisible*o3>+B#style.visibility<*LO%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LOD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*LOD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*LD' =1:Bvisible*o3>+B#style.visibility<*L%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*LD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*LD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*L D' =1:Bvisible*o3>+B#style.visibility<*L %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*L D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*L D' =1:Bvisible*o3>+B#style.visibility<*L %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*L D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*L~D' =1:Bvisible*o3>+B#style.visibility<*L~%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*L~D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*L~+8+0+LB +&&  PP( w Pr P S ,Bx   B  P S (Bx<$D  0 B H P 0޽h ? T3f3f$$___PPT10#.+uw*D#' = @B DA#' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PD' =1:Bvisible*o3>+B#style.visibility<*P%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PvD' =1:Bvisible*o3>+B#style.visibility<*Pv%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PvD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PvD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PvD' =1:Bvisible*o3>+B#style.visibility<*Pv%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PvD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PvD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PD' =1:Bvisible*o3>+B#style.visibility<*P%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PD' =1:Bvisible*o3>+B#style.visibility<*P%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*PLD' =1:Bvisible*o3>+B#style.visibility<*PL%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*PLD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*PL+8+0+PB +&&  TP(  Tr T S ,Bx   B  T S Bx<$D  0 B H T 0޽h ? T3f3f$$___PPT10#.+uw*D#' = @B DA#' = @BA?%,( < +O%,( < +D' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TD' =1:Bvisible*o3>+B#style.visibility<*T%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TZD' =1:Bvisible*o3>+B#style.visibility<*TZ%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TZD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TZD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TZuD' =1:Bvisible*o3>+B#style.visibility<*TZu%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TZuD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TZuD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TuD' =1:Bvisible*o3>+B#style.visibility<*Tu%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TuD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TuD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TD' =1:Bvisible*o3>+B#style.visibility<*T%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TD' =%(D`' =%(D' =A@BBBB0B%(E5' =1B B`BPB,54*3>B ppt_c='`B@BPB<*TZD' =1:Bvisible*o3>+B#style.visibility<*TZ%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*TZD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*TZ+8+0+TB +&&  XP( w Xr X S Bx   B  X S |BxP`p<$D  0 B H X 0޽h ? 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