The theoretical foundations of trauma care and the essential characteristics
of trauma systems have been continually refined over the past 30 years.
The following discussion provides a summary of system development based
on the circumstances that prompted progressive development including
shifts in public interest, changes in government policy, and establishment
of priorities within professional associations.
The organized care of injured patients has its roots in military models
of trauma care; many of the advances in caring for major trauma patients
can be attributed to the lessons learned during past military conflicts.
During World War II, well-developed triage systems were instituted and
wounded soldiers were evacuated through tiers of increasingly capable
medical care. Throughout the Korean and Vietnam wars, the time from injury
to definitive treatment was sharply reduced by transporting patients
with serious injuries directly to acute care field military hospitals
that delivered immediate, organized trauma care. Although the principles
learned during wartime were not automatically or easily implemented at
home, the military ' s success in dealing with severe injuries led to
heightened public expectations about trauma care and provided an impetus
for the development of trauma systems.
The first defacto trauma centers were municipal hospitals in major urban
areas that mostly provided emergency services to the uninsured. Because
these hospitals were usually affiliated with medical schools, injured
patients received timely treatment from in-house staff officers while
these staff members gained expertise in dealing with injuries. This concentration
of expertise and the early development of centers of excellence for trauma
care contrasted sharply with the care in suburban hospitals in the same
geographic area, which did not have a similar systematic response for
injured patients.
Community and public education regarding the status of EMS and trauma
care peaked in 1966 with the publication of the classic National Research
Council/National Academy of Sciences white paper Accidental Death and
Disability: the Neglected Disease of Modern Society." 1 This landmark
document reflected the gross deficiencies in prehospital care and proposed
a long range plan for changes in every facet of emergency care. This
farsighted report provided the basic blueprint and building blocks for
subsequent improvements in EMS programs nationwide but fell somewhat
short in describing the need for systems of care. Congress responded
to publication of this white paper by enacting both the National Traffic
and Motor Vehicle Safety Act and the Highway Safety Act of 1966, which
summoned a national commitment to reducing injuries on the nation's highways.
The Department of Transportation was empowered to set motor vehicle standards,
fund research and programs that promoted highway safety, provide leadership
for the development of regional EMS systems, and develop standards for
EMS provider training. States were required to include EMS as part of
their highway safety programs. Several prototype emergency medical systems
were developed under the auspices of this funding that identified the
essential characteristics of regional trauma systems and provided the
first indications that implementation of such systems saved lives 14-16
. The unique design of an early system, the Illinois Trauma Program,
which incorporated both urban and rural areas, utilized a controlled
systems approach that profoundly influenced future trauma system development
17 . Based on this original legislation from 30 years ago, the National
Highway Traffic Safety Administration (NHTSA) continues to develop and
implement EMS programs and other traffic safety programs today.
The EMS Systems Act of 1973 was perhaps the single most important piece
of legislation affecting the development of regional emergency and trauma
care systems. The Act called for the creation of a lead agency under
the Department of Health, Education and Welfare and identified 15 components
(one being trauma systems) to assist system planners in establishing
areawide or regional EMS programs. At that time, regionalizing services
was viewed as one way of distributing resources more equitably while
expanding access to health care systems. A substantial amount of federal
funds were devoted to the establishment of an EMS infrastructure in over
300 EMS regions nationwide. A primary failure of the Act, however, was
its inability to adequately stimulate initiatives to continually fund
EMS at the local level.
In 1981, funding sharply declined when the Omnibus Budget Reconciliation
Act altered the method of allocating federal EMS funds. EMS and trauma
system funding was consolidated into the state preventive health block
grant program. The purpose of the block grant concept was to shift responsibility
of funding for EMS services to the states while still providing support
for lead agencies that direct EMS services. States were given wide discretion
regarding the use of health funds; many regional EMS management programs
lost funding and were dismantled due to this change, while others responded
by increasing their involvement in EMS system development. At the same
time, several pivotal studies highlighted the relationship between untoward
patient outcomes and lack of surgical support or delays in caring for
injured patients, which drew public attention and accelerated progress
towards systems development in some areas 18-21 .
In 1984, Congress authorized the Emergency Medical Services for Children
(EMS-C) Program to support state-of-the-art emergency medical care for
injured children and adolescents. Although the program focused on the
entire continuum of pediatric emergency services, the intent was to ensure
that pediatric services were fully integrated into trauma systems. In
addition, the National Pediatric Trauma Registry was established in 1985
to study the causes, circumstances and consequences of injuries to children.
In 1986, the National Research Council and the Institute of Medicine
conducted a 20 year follow-up analysis of advancements made since the
1966 white paper focused the nation's attention on EMS. Although the
authors of "Injury in America: A Continuing Health Care Problem" concluded
that considerable funding and effort had been utilized to develop systems
of care, little progress actually had been made towards reducing the
burden of injury 2 . A conceptual pathway for the field of injury control
was introduced in this report that called for a major investment in research
related to the epidemiology of injury and development of parallel prevention
programs. The committee successfully advocated for the creation of a
new injury research center to lead national efforts in injury control
and establish research programs related to all aspects of injury including
prevention, pre-hospital care, acute care, and rehabilitation. The Centers
for Disease Control (CDC) was chosen as the site for this new center
because of the CDC's strong relationship to state health departments
and emphasis on research rather than regulation. Today, this program
continues to fund trauma related research and support the growth of Injury
Control Research Centers across the US.
1988, the NHTSA provided additional requisite resources for trauma system
development and evaluation through establishment of the Statewide Technical
Assessment Program and the Development of Trauma Systems course. The
technical assessment team approach has been used by states to assess
the effectiveness of individual EMS system components, as well as the
interrelationship of these components in producing a comprehensive system
22 . The Development of Trauma Systems course provided states and regions
with a detailed tool for system development that was tailored to their
individual needs 23 .
The Trauma Care Systems Planning and Development Act of 1990, which
created Title XII of the Public Health Service Act (PHSA), was enacted
to improve emergency medical services and trauma care. From 1992-1994,
funds were appropriated to carry out the responsibilities specified in
this Act and administered by HRSA. The program was not funded in FY95.
Under this program, a model trauma care system plan to use in trauma
system development was written by a consensus panel of experts. 8 Many
states were making significant progress 25 when Congress failed to reauthorize
resources for the program in 1995. It was funded again in FY2001 and
2002. Title XII of the PHSA is responsible for improving trauma and emergency
medical care through system improvement. This goal is accomplished through:
(1) a grant program available to State EMS offices to improve the trauma
care component of the EMS plan; (2) a grant program to improve rural
EMS care; and (3) discretionary activities including research, evaluation,
and grants for special EMS/trauma initiatives.
In the midst of these changes in federal policy and funding, professional
health care associations have also provided guidance for trauma system
development. The American College of Surgeons Committee on Trauma (ASCOT)
made substantial contributions to the conceptual framework of trauma
care systems by advocating for a network of trauma centers with verified
capabilities. ASCOT assumed the mantle of leadership in 1976 by identifying
the key characteristics for categorization of hospitals as trauma centers
in the first edition of their publication, "Optimal Resources for
Care of the Seriously Injured". 5 Through successive revisions,
this document became recognized as the standard for trauma hospital performance.
In 1987, ASCOT developed an external review program to verify hospital
capabilities, which provided further incentives for the designation of
trauma centers. Recently, ASCOT published a multidisciplinary work group
document entitled, "Consultation for Trauma Systems," which
provides guidelines for evaluating trauma system development and making
system enhancements 10 . In addition, the American College of Emergency
Physicians (ACEP) published "Guidelines for Trauma Care Systems," which
provided a detailed description of critical prehospital care components
in a trauma system 6 .
In 1999, the Institute of Medicine (IOM), with support from several
private foundations, published its third assessment of the public and
private response to injury. The report provided evidence of significant
advances in trauma system development but also highlighted the profound
gap between the current investment in system development and the magnitude
of the injury problem 4 . The group recommended additional funding for
surveillance, research, training and program evaluation by federal agencies.
Recent events have even further accelerated the momentum for the development
of a nationwide trauma system. The Skamania Conference held in July 1998
reviewed the medical literature to quantify current understandings of
trauma system effectiveness and proposed a plan for research in trauma.
Participants included representatives of many different specialties in
addition to trauma experts. A key recommendation from this conference
was to use a national consensus process involving a spectrum of national
committees and organizations interested in trauma care and prevention
to design a vision document describing a trauma system for the future,
including current status, a future vision, and an implementation strategy
based on valid, reliable data. The Skamania Conference also recommended
renewed federal funding for trauma system development.