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.
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 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
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.
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.
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.
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.
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
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
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.