Healthcare reform must address trauma care

A trauma network is an organized, coordinated effort that delivers the full range of care to all injured patients in a defined geographic area and is integrated with the local public health system. An effective trauma network enables a seamless transition between each phase of care—from the prehospital engagement to acute care facility treatment to posthospital care—in a patient-centered, cost-effective manner.

According to the National Highway Traffic Safety Administration’s report, Trauma System: Agenda for the Future, a comprehensive trauma system has many different components and requires the following eight key elements: leadership, professional resources, education and advocacy, information, finances, research, technology, and disaster preparedness and response.

Trauma care is a significant portion of healthcare costs. In 1995, the total cost of injury in the United States was estimated at $260 billion; injury and its consequences accounted for 12 percent of all medical spending. More than one million Americans survive traumatic events, but have resulting life-long disability. In 2000, the Centers for Disease Prevention and Control estimated that trauma resulted in $68 billion in productivity losses due to continued disability.

A short history
Civilian prehospital care had its roots in the first hospital-based ambulance service, established in1865 by the Commercial Hospital in Cincinnati, Ohio. In 1869, Bellevue Hospital began the first municipal-wide ambulance service in New York City.

Paramedical care—which expanded the role of the prehospital care provider to include fluid resuscitation, airway management, administration of medications, and advanced means of proper patient immobilization and transportation—began in the late 1960s.

In 1966, the National Academy of Science/National Research Council released its seminal report, Accidental Death and Disability: The Neglected Disease of Modern Society. The report noted that a soldier injured in Vietnam had a higher likelihood of survival than a similarly injured civilian in most parts of the United States. As a result, the federal government initiated a series of moves to organize trauma care.

For example, the National Highway Safety Act (NHSA) of 1966 provided funding and identified responsibility for several steps in the path toward organized trauma care and prevention. It mandated car safety features; advocated use of medical helicopters, radio communication, and development of ambulance services; and provided both oversight, through the Department of Transportation, and funding for many of these provisions.

As a direct result of the NHSA, Maryland, Florida, and Illinois enacted regional trauma systems. These early systems were partly funded by the federal government, but remained state-controlled.

Trauma care in Maryland was championed by R. Adams Cowley, MD, a pioneer in the field.

Dr. Cowley was a cardiac surgeon whose initial research in treating shock led to the concept of “the Golden Hour.” In 1969, he brokered an agreement with the Maryland State Police to provide medical helicopter service for the prehospital transport of trauma patients. His center grew into the Maryland Institute for Emergency Medicine, later renamed the R. Adams Cowley Shock Trauma Center.

On the other side of the country, under the medical direction of physicians at Harborview Medical Center in Seattle, Wash., MedicOne of King County evolved as a sophisticated system that integrated the resources of the fire department, Harborview Medical Center, and the University of Washington. This effort brought advanced medical care to patients in the field with standardized protocols, medical oversight, rigid training, and performance analysis.

Trauma care
Few areas of medical training are as standardized as trauma care. The Advanced Trauma Life Support (ATLS) course, under the aegis of the American College of Surgeons (ACS), sets provider standards. Several courses have evolved from ATLS, including those for medical students, registered nurses, and prehospital providers. ATLS is now widely accepted, even at an international level, as the standard for initial trauma patient management.

ATLS had roots in a 1976 plane crash involving James K. Styner, MD, an orthopaedic surgeon in Nebraska, and his family. His wife died in the accident, and three of his four children were taken to a local hospital. The lack of resources and organization led Dr. Styner to devise a course for trauma care providers to improve the standard of care. The first ATLS course was held in 1978, and ATLS education was taken over by the ACS in 1980.

Trauma centers
The first designated trauma centers in the United States were Maryland’s Center for the Study of Trauma and Chicago’s Cook County Medical Center. Although no national standard for trauma center designation exists, many states use trauma-level designations to identify which hospitals have specific resources.

In 1987, the ACS Committee on Trauma (COT) began a process of trauma center verification. The ACS-COT book, Resources for Optimal Care of the Injured Patient outlines established criteria and the requisite resources for a given level of care. A state or region may designate a trauma level, with or without utilizing the criteria of the ACS-COT, or a hospital may, in many regions, choose to seek ACS-COT verification.

While many regional differences among trauma level designations exist, standard performance metrics have been developed. The Injury Severity Score (ISS), for example, is an age-adjusted predictor of mortality. Together with other key data points, ISS information is collected by trauma centers and managed by the ACS National Trauma Registry. This national data bank of trauma outcomes is essential in the efforts to improve care of the injured patient.

According to the Orthopaedic Trauma Association (OTA), a Level 1 trauma center must have several essential resources for the optimal care of patients with musculoskeletal injuries. These resources include the following:

• an orthopaedic surgeon committed to the care of injured patients
• appropriately trained staff and services available in operating rooms, wards, and clinics
• an accessible operating room, 24 hours a day, 7 days a week
• anesthesia, nurses, and technologists familiar with orthopaedic trauma care procedures
• appropriate equipment and supplies needed for care

In addition, a well-functioning trauma network requires pre-established guidelines and provisions for inter-institutional transfer based purely upon medical need, prompt and equitable reimbursement for orthopaedic trauma care, and the availability of appropriate outpatient care after hospitalization for orthopaedic trauma.

Healthcare reform and trauma
As debate over healthcare reform continues, it is important to realize that guaranteeing health care for all Americans will not necessarily solve the trauma crisis in many states. On-call availability and access for orthopaedic emergency medical care is part of a national crisis in trauma care. Ultimately, coordinated, efficient, well-staffed trauma systems will improve patient outcomes and access, reduce morbidity and mortality, and decrease healthcare costs. The development of a national trauma system program must be an integral part of any healthcare reform proposal.

Samir Mehta, MD, and A. Alex Jahangir, MD, are recipients of the Washington Health Policy Fellowship; James W. Barber, MD; Fraser J. Leversedge, MD, and James C. Krieg, MD, are members of the 2009–2010 class in the AAOS Leadership Fellows Program.

Did you know…?

• Georgia has 15 trauma centers serving 10 million people over 59,000 square miles.
• Doubling the number of trauma centers in Georgia could save at least 700 lives per year.
• For every trauma death in Georgia, three persons are severely disabled due to trauma.
• Every $1 of physician charges for orthopaedic care at a trauma center generates $3.86 in facility charges.
• For every $1 that a physician collects for orthopaedic care at a trauma center, the facility collects $7.81.

References:

The National Highway Traffic Safety Administration, Trauma System: Agenda for the Future

Committee on Injury Prevention and Control, Institute of Medicine. 1999. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC, National Academy Press.

Centers for Disease Control and Prevention: Burden of Injury. MMWR 2008; 57 (pg 11)

Orthopaedic Trauma Association, the OTA Committee on Health Policy and Planning, Orthopaedic Trauma Service Organization

Final Report of the Joint Comprehensive State Trauma Services Study Committee, Georgia Senate Research Office, 2006

Vallier HA, Patterson BM, Meehan CJ, Lombardo T: Orthopaedic traumatology: The hospital side of the ledger, defining the financial relationship between physicians and hospitals. J Orthop Trauma 2008;22:221-226.