Trauma System Agenda for the Future
 

Index

What is Trauma

What is Trauma Systems

The Vision

Executive Summary

Introduction

Comprehensive Trauma Care System: Fundamental Components of Trauma Care

Comprehensive Trauma Care System: Key Infrastructure Elements

Conclusion

Glossary

References

Appendices

Appendix A - Summary of Recommendations

Fundamental Components of Trauma Care

Injury Prevention

•  Each State will have a core injury prevention program that provides assistance to local areas, with information and materials coordinated via a central repository or clearinghouse.

•  Trauma registry data will help with problem identification and program evaluation and will be fully coordinated with the EMS and public health systems.

•  A comprehensive study of the epidemiology of injuries and trauma will be conducted and predictive models regarding injury occurrence will be developed.

•  Injury prevention legislation will be enacted, where compelling evidence exists.

•  Injury prevention efforts will be conducted on a collaborative basis, with input from and the involvement of multiple stakeholders and constituency groups.

•  Injury prevention will be recognized as a legitimate public and governmental activity, similar to other safety programs such as fire prevention. Proper funding will be secured for injury prevention, with a greater portion of public health dollars allocated for injury prevention.

•  Injury prevention efforts will be seen as a legitimate health care cost that is directly reimbursable to providers.

•  Injury prevention programs, and their availability to the general public, will be required by lead agencies who designate all levels of trauma centers and by the public health systems.

•  Injury prevention will be integrated into existing health delivery systems, such as pediatric and rural health clinics, and prevention materials will be readily available at places where families usually receive care.

Prehospital Care

•  EMS and first responders will be more integrated within the health care system, with links to prevention and acute care, and will be more focused on promoting overall community health, as described more fully in the EMS Agenda for the Future.

•  Trauma care will be coordinated and integrated using standard protocols and triage. Triage criteria will be redesigned to ensure more accurate assessment, which facilitates direction and placement of patients to the most appropriate care setting.

•  Transport vehicles (air and ground) will be strategically placed rather than facility based and will be used appropriately to facilitate rapid access and response, especially in areas that are least accessible.

•  A national 911 system, covering both wireless and wireline telephone systems, will be developed and implemented, with standard, seamless protocols that are evidence-based and that address bystander interface. Access to prehospital trauma care in rural areas will be greatly enhanced through development of consistent standards and more efficient deployment of limited resources.

•  Enhanced communications among all components of the trauma care team during the pre-hospital phase will speed deployment of resources, produce more appropriate triaging, and result in better patient outcomes.

Acute Care Facilities

•  There will be a distributed system of acute care facilities and trauma care systems will be implemented across the country.

•  Research will be conducted to determine the effectiveness of the current tiered resource allocation guidelines.

•  The appropriate volume of patients with specific injuries that are needed at the highest echelon of care will be studied and clearly identified so that research and treatment options can be continually explored.

•  Trauma systems will be linked on a regional basis through databases and technology to ensure efficient and effective patient care nationwide.

•  There will be consistent standards for rural and urban trauma services, with the goal of every community having access to a consistent level of trauma care.

•  All injury care providers within a community will be recognized as part of the system and will provide data to a system-wide database, and injury care will be monitored throughout the system.

•  Most facilities, whether small community hospitals or large tertiary care centers, will have a designated role to play in the trauma system and the capacity to manage injured patients to one degree or another.

•  Facilities in the system will have multi-casualty capabilities.

•  The appropriate match of resources will be identified for injured patients with special needs, such as elderly, remote rural, or pediatric patients.

•  Innovative treatment methods will be explored, including utilization of mobile trauma units for rural areas.

Post-Hospital Care
  • Long-term care coverage will be available, affordable, and encouraged to help address post-hospital care needs.
  • Post-hospital care will focus on helping patients achieve greater independence,
    a higher degree of functionality, and a faster return to productivity.
  • Functional recovery will go beyond traditional rehabilitation and include psychological support.

•  Home-based care and monitoring will be used to manage costs and speed recovery, especially in areas lacking access to care.

•  Appropriate support groups will be established and encouraged.

•  Trauma Registry data will include post-hospital care and rehabilitation so that the value and cost-effectiveness of the full cycle of trauma care can be more readily assessed.

•  Research concerning the effectiveness of post hospital care will be supported.

Comprehensive Trauma Care System: Key Infrastructure Elements Leadership

•  A National Trauma System Leadership Council will be developed to advocate for system development in a facilitative manner, serve as the locus for policy development and support, and coordinate the work of federal agencies and professional organizations with injury-related programs.

•  All states will establish a Lead Agency to coordinate and administer trauma system development.

•  A best practices study will be conducted to identify the optimal components and configuration for local and state lead agencies.

•  The effectiveness of trauma system elements will be continually examined.

•  State legislators and governors will be informed about the need for an identified and adequately funded lead agency for trauma systems in their region .

Professional Resources

  • Professional resources in the system will be patient focused, team-oriented and physician led.
  • New categories of providers and the use of physician extenders will address the need for additional resources.
  • Creative opportunities for recruitment and retention of personnel will be explored.

•  Reimbursement for all types of providers will be appropriate and sufficient so as to encourage participation in trauma care.

•  Incentives for attracting trauma specialization, including addressing the burden of liability, will be explored.

  • Ongoing professional education opportunities will be available and accessible.
  • Volunteers will supplement career resources and will be enlisted to promote injury prevention as well as deliver care.
Education and Advocacy

•  A compelling educational campaign will be launched to position trauma and injury as a disease rather than a random occurrence and to increase public awareness of the need for injury prevention and the value of trauma care.

•  Targeted educational programs will be developed to inform policy makers about the value of community-based trauma care in order to promote passage of legislation to support trauma system activities, including injury prevention.

•  Trauma care providers and advocates will form or integrate into coalitions with trade associations, large corporations (such as Johnson and Johnson's work with the Safe Kids campaign) and payers to conduct public education programs about injury and injury prevention and to advocate for legislation to support injury prevention and trauma system activities.

•  Health insurers will have a clear appreciation of the cost effectiveness of injury prevention and will provide incentives for safe behavior.

•  Communication, education, and training approaches for the public and key constituency groups will be thoroughly coordinated yet distinctly segmented and targeted to achieve maximum impact.

•  The number of injuries and trauma cases will be reduced through education and training of clinicians, management and administrative personnel, volunteers, community support groups, potential "bystanders," and other key constituency groups.

•  Trauma and injury prevention education and training will be increased for all healthcare professionals, beginning at post-graduate levels and continuing throughout their careers, appropriate to the level of their involvement in health risk assessment, primary care, or injury care.

•  Advocacy efforts will facilitate passage of new laws designed to reduce injuries and trauma cases (based on evidence) and stronger enforcement of existing laws.

•  Tort reform will be enacted to facilitate greater access to trauma services and facilities.

•  There will increased awareness of the vulnerability of the older population.

Information Management

•  A national database and uniform data standards will be used to facilitate hospital operations and provide regional and national information regarding availability of post-hospital care.

•  Trauma care will be designated as a specific research area for epidemiological study. Predictive models will be developed regarding outcomes and will be used in making funding and resource deployment decisions.

•  Pre-hospital and functional outcomes will be tracked and used in a Total Quality Management initiative to improve policies, procedures, and processes throughout the trauma continuum.

•  Information related to the complete cycle of trauma-from prevention to post-hospital care-will be collected, analyzed, and made available to facilitate improvements in injury prevention, response times, patient care, and rehabilitation.

•  Information systems should be usable for multi-center studies.

•  A standardized training course will be used to enable trauma registrars to collect and categorize data in a consistent, comparable manner.

•  Clear evidence will exist to document the contribution of an injury management system (prevention and treatment) to a community's overall health, and additional research will demonstrate which components of a trauma system provide the most value.

•  Tools will be developed and region-specific injury data will be available to assist communities in making decisions about their specific needs related to trauma system development, particularly which components will best meet community health needs.

•  The culture of quality improvement will shift from using data to blame individuals to using the data to improve performance of the system.

•  Access to and appropriate protection of patient records and quality improvement data will be addressed through legislative and regulatory changes at state and federal levels.

•  Efforts to enhance patient confidentiality should be balanced with the need for strong research.

Finances

•  Trauma systems will be recognized as a public good and therefore valued and adequately funded not only for the clinical care they actually deliver, but also for the level of readiness required to meet the needs of all injured persons.

•  The appropriate level of readiness in a community will be determined by a broad-based group of community members, including citizens, local employers, trauma and health care providers, and payers.

•  There will be a "rural modifier" to the Medicare fee schedule for rural EMS providers.

•  There will be dedicated funding for trauma system infrastructure costs.

•  An open dialogue with managed care organizations, public and private, and other payers will facilitate greater mutual understanding of the costs of providing health care, ultimately leading to equitable payment mechanisms, which may include "carve outs" or risk sharing.

•  There will be ongoing dialogue and review regarding the cost-effectiveness of trauma care systems.

•  A system will be created for reimbursing providers for uncompensated trauma care without cost shifting to non-governmental payers .

•  The public will be encouraged to obtain long-term care coverage to augment other forms of payment for post-hospital care.

•  Alternative payment mechanisms will be examined, tested, and piloted, especially in rural areas.

•  Additional funding sources, such as seized drug money, will be explored.

Research
  • Congress will establish a National Institute for Injury, within the National Institutes of Health.
  • Federal agencies involved in or funding trauma research will be coordinated through a formal institutional process.
  • There will be formal efforts to interest young professionals in trauma research and there will be sponsored training programs in all types of research.
  • Types of research conducted will include fundamental basic research, crash investigation research, evidence-based medicine, best practices, clinical trials, clinical guidelines, and health services and systems research.
Technology

•  Automotive telematics systems and GPS in motor vehicles will be used to locate crashes, monitor vital signs, and determine injury severity. GPS will also provide real-time route navigation for ambulances.

•  Access technologies such as ACN and wireless E9-1-1 will be fully developed.

•  Various technological innovations will be used to provide services remotely.

•  Monitoring devices will be used in a variety of settings, including computer chip implants to monitor patients and the use of monitoring devices in a patient's home, which would support injury prevention and rapid response.

•  Computer chips will enable automatic transfer of sophisticated crash information and will permit injury research databases to be utilized to evaluate and improve auto design.

•  An artificial neural network will determine the most appropriate site for patient care, given the extent of a patient's injury.

•  Access numbers will be consolidated to eliminate confusion and streamline access nationwide.

•  Patient simulation technology will be used for provider education.

•  Medical input will be sought early in the design phase of future technologies to ensure that these developments are coordinated with the health care system and result in improved patient outcome.

•  Dedicated resources will be available for technology analysis.

Disaster Preparedness and Response - Conventional and Unconventional
  • Trauma systems will be an integral part of regional and state disaster plans and will integrate with efforts of the public health system to provide disaster preparedness.
  • Trauma and EMS systems will be integrated with other resources through the incident command system and will coordinate in advance with other regional resources such as law enforcement and public health.
  • There will be targeted education covering all weapons of mass destruction (identification and response) for all providers.
  • Hospital-based decontamination will be available in addition to more traditional field decontamination.
  • A nationwide network of hospital and community surveillance systems will enable rapid identification of all major health threats, including those related to weapons of mass destruction. EMS electronic data systems will be an integral part of this surveillance system.
  • Emergency communications systems will connect all levels of the response infrastructure, but will be developed with redundancy to assure backup when needed.
  • The public health infrastructure will be reinforced to enable it to more effectively respond to emerging threats.
  • Medical command centers will be an integral part of disaster incident command or incident management systems, to assure the most appropriate medical response.
  • There will be an optimal resources document for the role of trauma systems in disaster preparation and response.