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

Key Issues in Developing Inclusive Trauma Systems

A number of issues must be considered in planning an inclusive trauma care system for the future. These include the following:

The concept of inclusive trauma care systems promotes regionalization of trauma care, so that all areas of the country receive the best possible care. Equally important, an inclusive trauma care system must identify high-risk behaviors in each community and the population groups at risk for injury so that the system can provide an integrated approach to care that is responsive and appropriate to local needs.

Disaster Preparedness

Historically, the overwhelming majority of all manmade disasters or incidents of terrorism have involved explosives and have resulted in large numbers of people with life and/or limb threatening injuries. Though future acts of terrorism may include the use of other less conventional weapons of mass destruction (chemical, biological or radiological), they will most likely continue to involve use of explosives. In light of this experience, disaster medical response is best provided through an extension of existing resources within a trauma system. The best strategy for a community to prepare for disasters is to create a strong EMS and trauma system infrastructure that will deal with daily injuries and have the capacity to efficiently expand to respond to the demands of an unconventional or natural disaster of greater magnitude.

Trauma must be recognized as a disease process. Trauma has seasonal variations and trends, and characteristic demographic distribution. It is also age dependent. Like heart disease and cancer, trauma has identifiable causes, established means of treatment, and defined means of prevention. But unlike heart disease, trauma is communicable. People injure other people. Attitudes toward risk-taking behavior-such as running red lights or driving while under the influence-can spread throughout a community. Injury is not an accident; it is a predictable and preventable disease.

Designated trauma centers (Level I and Level II) are only one component of a trauma care system. Appropriate care must be provided along a continuum that includes prevention, pre-hospital care, care at all acute care facilities and trauma centers, and rehabilitation.

Trauma Requires a Multidisciplinary Approach

Trauma is a disease requiring a multidisciplinary team response. There is no question that committed and skilled surgeons interested in trauma care are essential to any properly organized trauma system. These specialized providers must be immediately available for definitive surgical intervention. However, many health care professionals along the continuum of care take part in providing care to the traumatically injured patient, including prehospital EMS providers, EMS medical directors and hospital physicians of all specialties, nurses, and allied health professionals. The appropriate use of all members of the trauma team must be planned to provide quality care in a timely and cost effective manner. Cost Effectiveness

The current cost of delivering trauma care is overwhelming. Many emergency departments and hospitals - both trauma centers and non-trauma centers that are important to trauma care - are closing or refusing to care for trauma patients due to health care industry issues, including high cost, inadequate reimbursement and malpractice. 12 Because of the lack of Federal and state funds, development of comprehensive trauma systems is taking place in only a few states. A coalition of health professionals, elected officials, and other special interest groups is essential to correct the problem. With the total cost from trauma in the U.S. approaching $260 billion each year, combined with changes in health care financing, any system unable to decrease costs is certain to fail. 4 An inclusive trauma system with an emphasis on optimal resource utilization and prevention offers the best chance for success.

Enhanced public awareness and increased individual responsibility are essential. Injury surveillance to identify high-risk groups and the development of prevention countermeasures are also important parts of an inclusive trauma care system.

Appropriate care for the major trauma patient will continue to be expensive. The charge for the average trauma admission is two to four times greater than for the average general admission. However, trauma centers remain cost effective because they significantly improve survival and reduce disability. The amount paid in Federal, state, and local taxes by a rehabilitated trauma patient returning to work far exceeds the cost of trauma care.

Coordination of Resources, Services and Special Populations

An effective trauma care system will be part of, and interrelate with, many other components of the health care system. Duplication must be avoided and existing resources integrated. The capabilities of current EMS systems should be taken into consideration when developing a trauma system. An integrated EMS and trauma system should, through a coordinated effort, provide a continuum of care while addressing specialized patient needs such as pediatrics, burns, and spinal cord injuries. The system must also continue to coordinate trauma care within regions and, when needed, adjoining states, especially in rural and frontier regions.

Reimbursement, Funding and Legislation

Funding issues require a perspective that looks beyond the "costs" of development to consider the societal benefits of reducing the incidence of trauma and improving outcomes. Adequate funding is required to complete the creation of a national trauma care system where hospitals' capabilities to treat trauma is matched with the severity of trauma patients' injuries.

Funding for trauma is needed on several levels. National planning and development, leadership and research must be funded at a Federal level. These critical components have received partial and intermittent Federal financial support in the past. In fact, the goal today is to complete the job begun in the 1970's by the Emergency Medical Services Systems Act of 1973. This act grew out of the landmark study published in 1966 by the National Academy of Sciences and National Research Council, "Accidental Death and Disability: The Neglected Disease of Modern Society," which called attention to the deficiencies existing in American trauma care and stressed the need for comprehensive and organized care delivery. 1

In the early 1990s, the Trauma Care Systems Planning and Development Act of 1990 (P.L. 101-590) provided new opportunities for trauma system development and many states made significant progress until Congress failed to fund the program in 1995. New funds and enabling legislation are critical to the completion of this phase of trauma system development.

States and local communities also must be willing to finance emergency medical services to allow for a "level of readiness" necessary to provide appropriate trauma care services for all injured patients both on a day-to-day basis and in the event of a natural or unconventional disaster.

The Reality for Trauma and EMS in Rural, Remote, and Wilderness Areas

For the 65 million people living in rural America, the fragile health care infrastructure is especially relevant. In rural, remote, and wilderness areas the existing hospitals and other medical care facilities must serve as the safety net for initial stabilization of the time-critically injured prior to transfer to definitive care. This report recognizes the unique characteristics and needs of rural, remote and wilderness areas and the relevance of the EMS and trauma systems to people at risk.

The population in non-urban areas is spread over large areas, making local access to needed services difficult. These areas show higher rates of unemployment, lower median household income, and lower percentage of high school and college graduates. The population is typically older and has higher rates of chronic disease than the urban population.

The aging population, earlier discharges from hospitals, and closure of hospitals increase the demand for emergency services. The main barriers identified for rural, remote, and wilderness areas in providing emergency services include:

Low Volume; high fixed costs: The fact that the ambulance typically makes far fewer runs in non-urban areas than an urban service means that the cost per run of the non-urban service is much higher. Likewise, a typical non-urban hospital emergency department, which sees far fewer patients than an urban hospital, has a higher per-visit cost.

Volunteerism: As with many rural, remote, and wilderness enterprises, the ambulance service historically has relied on volunteers. Unfortunately, volunteerism- even in non-urban America- is on the decline.

Lack of Medical Oversight: There are currently four levels of national standard curricula for prehospital EMS personnel, with each level requiring more training. Each has more skills than the previous: first responders, basic emergency medical technicians, intermediate emergency medical technicians, and EMT-paramedics. Each emergency medical service agency, whether volunteer or paid, needs to have a physician granting authority and accepting responsibility for all aspects of the care provided by pre-hospital providers. Quality medical direction is essential to providing the best care. Due to shortages of physicians, particularly physicians trained in emergency medicine, in rural, remote, and wilderness areas, some EMS units have no medical director and EMS personnel may be the only healthcare providers readily available.

Why Act?

The benefits of successful implementation of this plan include: (1) a reduction in deaths caused by trauma; (2) a reduction in the number and severity of disabilities caused by trauma; (3) an increase in the number of productive working years seen in America through reduction of death and disability: (4) a decrease in the costs associated with initial treatment and continued rehabilitation of trauma victims; (5) a reduced burden on local communities as well as the Federal government in the support of disabled trauma victims; and (6) a decrease in the impact of the disease on "second trauma" victims-families.

Only about fifty percent of the United States is served by an organized trauma system. 24 As Americans move freely through the nation, each has a right to quality trauma care wherever he or she may live or travel. This country has accepted the right of each citizen to fundamental health care but, in the realm of trauma, not all citizens are served.