Regionalizing Emergency Care Workshop Summary (2010) / Chapter Skim
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1 Regionalized Trauma Care: Past, Present, and Future
1 Regionalized Trauma Care: Past, Present, and Future
Pages 11-24
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From page 11... ...
Eastman noted that true trauma system integration means that no matter where in the United States a trauma occurs, the patient is assured expeditious transport to the level of care that is commensurate with their injury, whether that is 10 minutes or 10 hours away. He argued that we should constantly remind ourselves this is an inclusive system, representing an entire continuum of care, not only the Level I trauma centers where the most critical patients go.
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From page 12... ...
The state established a lead agency within the Department of Health which aided in breaking the state down into regional groups and organizing the available hospital capacity. However, he said there were many emergency care-related functions in public health, transportation, and other parts of the government that were not under lead agency control, but should have been.
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From page 13... ...
Fildes said that the trauma system is the "oldest, best-studied, and best-validated example of a regionalized emergency care system." He added that the system is designed to ensure that if a person suffers a life-threatening injury or other emergency anywhere on the map of the United States, they will quickly move through a system of care that provides them with standardized and optimal care services. He said the Committee on Trauma came into being in the 1920s and began writing quality standards for ambulances.
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From page 14... ...
But nearly every state now has the legal authority to designate trauma centers. Also, the percent of the population living within 45 minutes to an hour of a trauma center nationwide is 70-80 percent, which is very good.
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From page 15... ...
Also, she said, there is a big difference between the percentage of people who have access to trauma care (i.e., the percent who live within a certain distance or time factor from a trauma center) , and how many people actually get to trauma centers.
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From page 16... ...
Noting that the 2006 IOM committee envisioned an emergency care system that is regionalized, coordinated, and accountable, he said that coordination must be established by someone, otherwise market forces will drive it. Finally, he observed, accountability requires not just data and quality measures, but also an enforcement arm to make sure that people are doing what they're supposed to be doing.
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From page 17... ...
There needs to be a top-down hierarchical approach to this with standardization at the state level and driven down into communities to make sure that emergency care functions across the entire continuum of prehospital and hospital care. He said the Emergency Care Coordination Center may be the group to take on that function.
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From page 18... ...
"That was the issue," Boyd said. "Wherever we had physician leadership -- first it came from surgeons, then from emergency physicians -- this lead agency concept came into play." Boyd said that the successful states were ones that maintained the lead agency concept.
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From page 19... ...
" Eastman noted that over-designating or having too many trauma centers dilutes the higher volumes that are needed to improve performance and outcomes. "That's really the dilemma that you have, [and]
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From page 20... ...
EMTALA imposed a mandate on hospitals, as well as physicians who provide emergency and trauma care, to provide a medical screening exam to all patients and to stabilize them or transfer them to an appropriate facility if an emergency medical condition exists. Wild argued that second- and third-order protocols are crucial in driving a regional system, because otherwise utilization will be "top-heavy," i.e., skewed toward the Level I providers.
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From page 21... ...
By changing the prehospital triage criteria and by getting the Level IIIs to do more, diversion rates at the Level I trauma centers are now down. He said this illustrates that a regional system of care must have hierarchical levels of care that function on a 24/7 basis.
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From page 22... ...
Fildes responded, "It comes down to again who's in charge. We could promulgate a standard that says those transfers are not optimal, but there's no effector arm, no disciplinary arm, because there's no air traffic controller in the tower." Holcomb noted that his Level I trauma center recently accepted a lip laceration case from an outlying hospital.
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From page 23... ...
Also, redirecting less serious cases to lower-level centers could help free up subspecialists during peak times. Neurosurgeon Alex Valadka noted that "most neurosurgical centers get overwhelmed by cases that probably don't need to be there, but could be safely managed at a Level III or a Level IV facility." Implications for Training and Residency David Sklar of the University of New Mexico and ACEP commented that, if we were to regionalize other care systems in the way that we have for trauma, there would be major implications for medical student training and residency.
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From page 24... ...
Having been involved in trying to regionalize a number of different types of services, he observed that "the major opposition to this consistently comes from academic health centers or academic university training programs because of the impact it can have on [their] training programs."
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