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6 Trauma Care
Pages 138-177

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From page 138...
... Since then, much progress has been made in developing systems of care that strive to reduce injury-related morbidity and mortality. Trauma care systems deliver a continuum of prehospital, acute care, and rehabilitation services.
From page 139...
... . In a trauma system, the integration of prehospital, acute care, and rehabilitation providers is administered by a public agency whose cardinal roles are to provide leadership, coordinate service delivery, establish minimum standards of care, designate trauma centers (offering 24-hour specialized treatment for the most severely injured patients)
From page 140...
... Acute Care Hospitals and primary care providers diagnose and treat the majority of injured patients, but the cornerstone of the trauma care system is the trauma center. Trauma centers are highly sophisticated facilities geared to the most gravely injured.
From page 141...
... Rural emergency medical services have lagged behind their urban counterparts for a host of reasons, including greater transport times, insufficient volume of patients to maintain the skills of providers, and too sparse a population density to sustain local public financing (OTA, 1989; HRSA, 1990~. In comparison with urban areas, rural areas experience higher mortality rates for motor vehicle crashes (Baker et al., 1987; Mueller et al., 1988; Flowe et al., 1995)
From page 142...
... , although adult trauma centers with a pediatric component may be able to achieve outcomes comparable to those of pediatric trauma centers (Pollack et al., 1991; Fortune et al., 1992; Knudson et al., 1992; Nakayama et al., 1992; Cooper et al., 1993; Hall et al., 1993, 1996; Rhodes et al., 1993; Bensard et al., 1994; Hulka et al., 19971. As important, targeted pediatric injury prevention programs have been shown in populationbased studies to result in substantial decreases in the incidence of serious childhood injuries (Davidson et al., 1994; Durkin et al., 19961.
From page 143...
... Federal legislation since the 1970s, such as the Emergency Medical Services Systems Act of 1973 and the Trauma Care Systems Planning and Development Act of 1990, channeled funds to states and regions in order to cultivate the development of systems of care (Table 6.1 contains a chronology of federal trauma system legislation)
From page 144...
... More specifically, the plan exhorts states to designate trauma centers, establish trauma registries, and ensure, in concert with communities, that triage and transport protocols are in place for the timely assessment and movement of patients to the most suitable acute care facility. Bazzoli and coworkers (1995)
From page 145...
... . Thirtynine states certify prehospital providers who have passed written and practical examinations administered by the National Registry of Emergency Medical Technicians, a nonprofit certifying organization (NREMT, 19981.
From page 146...
... Some of the leadership activities deemed to be essential were the provision of education to EMS providers on primary injury prevention, the protection of individual EMS providers from injury, and the collection and use of injury data (Garrison et al., 1997~. Although a number of primary prevention programs by prehospital and acute care providers have been implemented in various states or regions, none has been evaluated as yet (Kinnane et al., 1997~.
From page 147...
... . Most surveillance systems currently in place are kept by individual trauma centers as a condition of trauma center designation (Pollock and McClain, 1989~.2 In addition, although 48 percent of states have some type of hospital-based trauma registries, there is great variability in their nature, scope, purpose, and data elements (Shapiro et al., 1994~.
From page 148...
... It has formed the underpinning for improved patient care and survival, reduced morbidity, and a national investment in trauma systems. In recognition of its vital role in advancing the trauma field, the ACS requires Level I trauma centers to conduct an active research program.
From page 149...
... , five states were judged to have met the eight criteria. More states would have qualified except that they had failed to limit the number of trauma centers, depending on community need.
From page 150...
... More recent figures from the ACS Committee on Trauma, which began a program to verify centers in 1987, reveal that, from 1987 to 1997, 285 hospitals were verified by the ACS as trauma centers (G. Strauch, American College of Surgeons, personal communication, 1998~.
From page 151...
... They also determined that the Portland metropolitan trauma system, through its prehospital triage criteria, was successful at shifting more seriously injured patients to trauma centers. Similar results were found when the authors broadened their analysis to cover five categories of injury across the entire state of Oregon before and after the implementation of a statewide trauma
From page 152...
... Injury Severity and Case Mix Indicators used as a basis for assessing the severity of an injury include anatomical descriptors for assessing the extent of tissue damage; the mechanism
From page 153...
... Alternatives such as the Anatomic Profile (Copes et al., 1990) and the New Injury Severity Score (Osler et al., 1997)
From page 154...
... However, as more lives are saved, attention also is shifting to nonfatal outcomes. However, in measuring nonfatal outcomes following trauma, it is important to move beyond the use of narrowly defined measures of morbidity, impairment, and performance in basic activities of daily living to include more global measures of health status and health-related quality of life (HRQOL)
From page 155...
... An important issue is the extent to which available measures are sensitive to the cognitive deficits and behavioral changes that often accompany head injury. Broad application of appropriate health status and HRQOL measures using standard protocols is essential for developing benchmarks for trauma outcomes.
From page 156...
... are already in place. A state or region already equipped with an array of prehospital, acute care, and rehabilitation services geared for all types of trauma incurs modest additional costs to establish a trauma system, primarily for public administration, trauma center designation, and coordination; whereas a region without a continuum of care and with no public commitment to systemwide integration may incur substantial start-up and maintenance expenditures.
From page 157...
... would be incurred by trauma centers treating the severely injured if such centers were available throughout the United States. Even though only 12 percent of trauma patients are severely injured, they disproportionately incur 26 percent of the charges (MacKenzie et al., 1990~.
From page 158...
... For example, a recently published analysis of 13 previously published data sets found that helicopter medical transport is costeffective in terms of cost per year of life saved, and is more cost-effective than other emergency medical interventions (Gearhart et al., 1997~. Helicopter and ground transport directly from the scene of injury to a trauma center led to significantly shorter lengths of stay and charges than did matched interhospital transfers (i.e., patients transferred to a trauma center from a local hospital; Schwartz et al.
From page 159...
... States have assumed responsibility for dispersing federal and state funds; developing, coordinating, and administering systems; designating trauma centers; and ensuring quality. Yet both federal and state activities historically have concen
From page 160...
... 3In FY 1997, the estimated funding for state and regional trauma systems was $11.9 million from the CDC Preventive Health and Health Services Block Grant and $12.5 million from the Emergency Medical Services for Children (EMS-C) Program sponsored by HRSA and NHTSA.
From page 161...
... One survey of 313 trauma centers in 1992 found that 58 percent reported serious financial problems and an
From page 162...
... The third factor is inadequate patient care financing by Medicare and Medicaid (MacKenzie et al., 1991; Mendeloff and Cayten, 1991; Hackey, 1995~. For example, Medicare's prospective reimbursement system, which has been adopted by some state Medicaid programs, did not adequately adjust reimbursement rates to account for the greater severity of patients' injuries seen in trauma centers, although Medicare did make an adjustment for this problem in 1991 (Dailey et al., 1992; Bazzoli et al., 1996~.
From page 163...
... This trend is likely to present new challenges in trauma care financing, the viability of trauma centers, and the quality of patient care in the future. The increasing cost of patient care provides financial incentives for payers such as employers and health insurers to embrace injury prevention, both in occupational and in nonoccupational settings.
From page 164...
... , in which a group of hospitals or physicians provides services to plan members at discounted rates, or mixes of the two (Gold et al., 1995~. In most PPOs and some HMOs, emergency care is provided through contracts with select EDs and trauma centers, whereas other HMOs provide emergency services directly.
From page 165...
... found that the mean LOS for 89 HMO trauma center patients in San Francisco from 1989 to 1993 were actually higher than those for non-HMO controls matched for
From page 166...
... The authors speculate that the possible reasons for the increased LOS among transferred patients are the disruption in continuity of care, problems in discharge planning, and medical complications that occur after transfer. On the other hand, a study of 3,141 admissions from 1990 to 1992 to a Seattle trauma center found LOS to be similar among motor vehicle crash patients with and without commercial insurance (Rhee et al., 1997~.
From page 167...
... The committee recommends intensified trauma outcomes research, including research on the delivery and financing of acute care services and rehabilitation. The committee envisions that HRSA and other appropriate federal agencies (e.g., NCIPC, AHCPR)
From page 168...
... The growth of managed care has placed further financial burdens on hospitals and trauma centers. The impact of managed care on trauma patient access, utilization, quality, and financing is essential to monitor but has been largely unexamined in the peer-reviewed biomedical literature.
From page 169...
... 1995. Trauma centers in a managed care environment.
From page 170...
... 1994. The economic status of trauma centers on the eve of health care reform.
From page 171...
... 1997. The role of emergency medical services in primary injury prevention.
From page 172...
... survivor outcome in Pennsylvania's trauma centers. American Surgeon 170:333340.
From page 173...
... 1992. Difference in trauma care among pediatric and nonpediatric trauma centers.
From page 174...
... 1989. Rural Emergency Medical Services Special Report.
From page 175...
... 1993. An analysis of the association of trauma centers with per capita hospitalization and death rates from injury.
From page 176...
... 1990. Do trauma centers improve outcome over non-trauma centers?
From page 177...
... Academic Emergency Medicine 4(~12~: 1 129-1 135.


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