In 1957, R Adams Cowley, M.D. (his first name really was just R, without a period), a noted Maryland cardiac surgeon, coined the idea of "the golden hour" — the 60 minutes after a severe traumatic injury during which the patient should receive appropriate care. If the patient does not receive such care during that first hour, the theory goes, his or her chances of survival drop significantly. Although the concept was controversial at first — with some critics saying it had no basis in science — over the years, it has been generally accepted.
The Birth of Trauma and Burn Centers
In 1958, Cowley founded the Shock Trauma Center at the University of Maryland Medical Center in Baltimore. It is widely considered to be the first Level I civilian trauma center in the United States. In 1966, the National Academy of Sciences released a groundbreaking report, "Accidental Death and Disability: The Neglected Disease of Modern Society," which highlighted the lack of competent trauma care and recommended a series of actions. Formal trauma center designation did not begin until the American College of Surgeons issued a landmark paper on the benefits of appropriate trauma care in 1976. Designation of trauma centers by state or local governments, often after verification by the ACS that the applicant center had the necessary resources, began shortly thereafter.
The history of burn centers is a bit more complicated. Specialized sites for the care of patients with serious burns began to develop in the United States in the 1940s, and tracking of their establishment probably began in 1947. Burn centers are "verified," which is equivalent to designation in the trauma field, through a joint program of the ACS and the American Burn Association.
A substantial portion of the improvement in both types of care over the years has come from progress in military medicine, which has long confronted trauma and burn injuries at a much higher rate than is seen in the civilian population. Cowley had served in the U.S. Army and, as David H. Ahrenholz, M.D., FACS, current president of the burn association and chief of the burn center at Regions Hospital, St. Paul, Minn., says, "Virtually all of the advances in trauma surgery have come as a result of war; military medicine is ahead of civilian medicine in this regard."
Yet, as Frederick B. Rogers, M.D., FACS, medical director of the trauma program at Lancaster (Pa.) General Hospital, wrote in 2010, "Civilian care was slow to adopt the advances in trauma care that derived from our military conflicts."
But eventually, the lessons of two world wars, Korea and, especially, the Vietnam conflict, made it plain that skilled field stabilization, swift transportation and appropriate, timely care can save many lives — and return the wounded young to productivity.
The ACS has largely been responsible for determination of standards for these specialized services, many of them detailed in its publication Resources for Optimal Care of the Injured Patient 2006. However, as the American Trauma Society explains on its website, "Trauma center designation is a process outlined and developed at a state or local level. The state or local municipality identifies unique criteria [with] which to categorize trauma centers. These categories may vary from state to state and are typically outlined through legislative or regulatory authority."
In other words, there are many cooks in this kitchen. Yet, they seem to work together well to ensure that the quality of trauma and burn care is as optimal as possible.
Verification, Designation — and Funding
We have come a long way since the pioneers of trauma and burn care began to advocate for specialized centers and properly trained clinicians. Centers are verified and/or designated, and, according to Jennifer Ward, R.N., president of the Trauma Center Association of America [formerly known as the National Foundation for Trauma Care] in Las Cruces, N.M., "Some states have developed a separate funding stream [for trauma centers], including Hawaii, New Mexico and Texas. Some comes from general funds; some is dedicated. In California, it is more county-based."
The Patient Protection and Affordable Care Act included three separate types of grants for trauma care, which were authorized by Congress but never funded. The foundation is advocating for reauthorization of the grants.
And the semipermeable barrier between trauma and burn care was made easier to penetrate when Congress passed, and President Obama signed, on Aug. 8 of last year, the Improving Trauma Care Act of 2014, which simply expanded the definition of trauma to include burns, which made burn centers eligible for certain federal grants for care and research.
A Varying Supply
Trauma and burn care have followed somewhat different trajectories over the years, although they are often joined at the hip. A burn, after all, is a form of traumatic injury. As Ahrenholz says, "To have a burn center in a community hospital means that it probably has to have a trauma center as well." Staffing and resource requirements are so massive, and the designation and verification process is so rigorous that, in many cases, you can't have one without the other.
But the supply of both types of centers has followed something of a roller-coaster pattern over the years. This is not unique to trauma and burn care; health care has its short-term trends, like any other sector. Mark Herzog, FACHE, president and CEO of Holy Family Memorial Medical Center in Manitowoc, Wis., terms this "the binge/purge cycle of fads and reactivity." But in health care, the stakes are higher than those involving the latest craze in basketball shoes.
The data emanating from various sources are somewhat conflicting, so the following information should not be taken as gospel. There are three major problems with the numbers:
• Trauma and burn centers open and close, often on short notice, and the data on such events often lag behind.
• Trauma centers, especially, can change their nature (there are five levels of designation, ranging from sophisticated tertiary centers — Level I — to what one observer has dubbed "glorified emergency rooms").
• There is no central repository for timely data on the supply of centers or dedicated beds, so statistics have to be cobbled together, and they are often inconsistent in comparison with each other.
What the Data (Such as They Are) Tell Us
That said, Peter Kralovec, executive director of the Health Care Data Center at Health Forum, an American Hospital Association subsidiary, reports that in 1990, 4.1 percent of U.S. community hospitals reported having a Level I trauma center. By 2000, that percentage had risen to 6.1 percent. In 2010, it was 9.4 percent. In terms of the number of hospitals, in 2000 (the first year for which detailed data are available), 258 hospitals reported having a Level I center; in 2010, the number was 387; in 2013, it was 416.
Yet, in May 2004, the then National Foundation for Trauma Care issued a report, "U.S. Trauma Center Crisis: Lost in the Scramble for Terror Resources," which argued that in the post-9/11 rush to divert resources to the consequences of terrorism, trauma centers were basically being ignored. (The same can be said for the more recent Ebola fever situation.) Furthermore, a growing number of physicians were resistant to being on call, especially at night, for trauma cases. And, as has long been true and still is today, many insurers and Medicaid programs were not falling all over themselves to compensate providers sufficiently for trauma care. Even inadequate reimbursement is usually unavailable for uninsured patients.
It is a major, and very expensive, commitment to operate these centers. As Donald Trunkey, M.D., FACS, professor emeritus in surgery at the Oregon Health & Science University, explains, "If you look across the country, you see that many universities consider caring for these patients to be a public good, and that is certainly true. But I am also sympathetic to the fact that it's very difficult to make money on trauma patients in low-income neighborhoods. The issue of providing trauma care in the inner city is a major problem. A lot of the worst problems are in the Southern states. In some areas, such as Boston, there is an excellent public hospital [Boston Medical Center], and they do a really good job, taking all the trauma patients. The same is true in Minneapolis, Omaha, Neb., Seattle and other places. If patients are at risk of dying, you can't use money as a measure for being admitted to a hospital.
"But you need orthopedic surgeons and neurosurgeons, and there is a shortage of neurosurgeons willing to take these patients. And with the patients coming back from Iraq and Afghanistan, traumatic brain injury is a real problem; many neurosurgeons do not want to treat these patients. And if you have a severely injured patient, you can get him or her through the acute care, but if he or she is in need of rehabilitation, that's another issue. Sometimes even acquiring a wheelchair becomes a major challenge."
The Door Opens, the Door Closes
So, although the total number of Level I trauma centers has increased, some centers have also closed. Renee Yuen-Jan Hsia, an attending physician at San Francisco General Hospital, and Yu-Chu Shen, associate professor at the Naval Postgraduate School in Monterey, Calif., wrote in the March 2014 issue of the Journal of Trauma and Acute Care Surgery that approximately one-third of all trauma centers have closed in the past 20 years. Of course, others have opened, as the data show.
In an earlier piece in Health Affairs, published in 2011, the same authors, using data from 2001 to 2007 (as was previously noted, the available data are often several years old), reported that in 2007, 24 percent of the U.S. population — nearly 70 million people at the time — had to travel longer to a trauma center than in 2001; of this population, nearly 16 million had to travel an additional half-hour or more. The authors attributed much of this increase in length of travel time to closure of trauma centers in both rural and urban areas. However, vulnerable low-income, African-American and rural communities were at greater risk.
Obviously, in the case of serious traumatic injury — and the importance of the "golden hour" — this is not a good trend. As Hsia and Shen noted in their 2014 piece, the risk of dying for patients whose trip to a trauma center had become longer was 21 percent higher than for patients whose travel time remained unchanged.
The authors concluded in their earlier article, "Trauma centers provide expensive care to higher proportions of vulnerable populations and are less able to recover their costs compared with hospitals without trauma centers … . And because there are no federal or state requirements dictating the number and level of trauma centers for any given community, the decision to close a trauma center is mostly driven by market factors and the hospital's mission" (Hisa and Shen, "Rising Closures of Hospital Trauma Centers Disproportionately Burden Vulnerable Populations," Health Affairs, October 2011). They further concluded that trauma center closures are more the result of economics than of poor performance or bad outcomes.
The Politics of Opening, Closure and Location
Trauma center closures have become a political issue in some places. One of the more contentious situations is in Chicago, where activists are pressuring University of Chicago Medicine to reopen its Level I trauma center, which was opened in 1986 and closed in 1988 after millions of dollars in losses. Since then, one hospital on the city's South Side pulled out of the Chicago trauma network, another closed its trauma center and a third closed entirely, probably leaving nearly half the city with insufficient trauma resources.
In January 2014, the American College of Emergency Physicians issued a state-by-state analysis of the availability and quality of emergency care, including trauma services. The group gave the overall situation in the United States a grade of D+. The percentage of state populations living within an hour's travel of a trauma center ranged from 100 percent in Connecticut, Delaware, New Jersey, Rhode Island and Washington, D.C., to 17.9 percent in Arkansas.
It would appear that there is a problem. But there are always dissenting voices. In the September 24, 2012, issue of USA Today, Phil Galewitz of Kaiser Health News reported that 200 trauma centers (of all levels) had been opened in U.S. hospitals since 2009, many by proprietary chains, especially HCA. Both competitors and analysts have questioned whether these centers are necessary. When HCA won approval to open a center in northern Florida, Jim Burkhart, then president and CEO of competing Shands Jacksonville Medical Center [now University of Florida Health–Jacksonville], which had the only trauma center in the area at the time, complained: "Adding new trauma centers will only increase costs for hospitals, taxpayers and consumers."
He wasn't the only one. Ellen MacKenzie, Ph.D., chairman of the Department of Health Policy and Management at the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, observed in the same article, "The more patients trauma surgeons take care of, the better they do in terms of treatment. But with too many trauma centers, you dilute that effect."
Furthermore, in March 2014, also in the Journal of Trauma and Acute Care Surgery, Joseph Tepas III, M.D., chief of pediatric surgery at the University of Florida Health–Jacksonville, and his colleagues published a study of the impact of the opening of a Level II trauma center where a Level I center already existed. (One presumes this was the disputed center.)
They concluded that "the addition of a second trauma center in a stable region, in which injury incidence was actually decreasing, doubled the cost of personnel, one of the most expensive components for the trauma system, and decreased the volume of injuries necessary for training and education. Trauma system expansion must be based on needs assessment, which assures [sic] system survival and controls societal cost."
One thing is sure: There is not widespread agreement on how many trauma centers the United States should have.
The Logistics of Burn Care
Burn centers are less common. Burn surgeon Alan Dimick, M.D., FACS, and his colleagues wrote in the Journal of Burn Care & Rehabilitation in 2008: "Burn center development in North America began in the mid-1940s, surged in the 1970s, and had reached every distinct medical market by 1985." At the time, the authors counted 137 active burn centers. By 2008, Dimick and a colleague wrote in the Journal of Burn Care & Research that of 175 burn centers, 25 had closed between 1947 and 1992, 153 had been active in 1992, and 125 were active in 2007. However, the authors noted, the supply of burn care beds was nearly the same.
The Health Care Data Center reports that in 1988, 135 hospitals had at least one bed for burn care; by 2013, the number had increased to 180. Not all of these beds, however, can be considered formal burn centers. The American Burn Association lists 128 burn centers as of 2014. California had at least 12; nine states had only one. Alaska, Idaho, Mississippi, Montana, New Hampshire, North Dakota and Wyoming had none.
This is not necessarily a calamity. Ahrenholz points out that "the number of burns in the United States has dropped; 32 years ago, there were 2 million burns annually, and now we believe that the number is down to 800,000. The number of serious burns is dropping at least as rapidly." And, given the enormous expense of burn care, the last thing the health care system needs is an oversupply of these centers.
Ahrenholz adds that telemedicine is helping with treatment of burns in rural and frontier areas. Consulting physicians can advise local providers as to "which burns need transport and which will heal in two weeks."
However, burns are a very common consequence of military combat and of airline disasters and other mass-casualty situations. A 2007 story by Bill Poovey in The Washington Post noted that "U.S. hospitals are increasingly shutting down their burn centers in a trend experts say could leave the nation unable to handle widespread burn casualties from a fiery terrorist attack or other major disaster."
Ahrenholz agrees: "Trauma and burn centers are a precious resource, and the American Burn Association goes to Congress once a year to remind them of that. If there is a mass-casualty disaster, we will be totally overwhelmed. We measure occupancy in burn beds, and the usual rate is 60 to 80 percent. Local resources will be totally overwhelmed, and the burn center in a hospital is possibly going to be one of the first casualties.
"If you want to demoralize a population, attack the health care system."
In the Right Place?
There is a related issue here, and that is the location of existing tertiary trauma and burn centers. Although there has been an increase in the number of trauma centers, the research and data seem to be consistent in concluding that they have been closed far more often in communities with vulnerable populations and opened more often in higher-income locations.
In Los Angeles County, the closure of some trauma centers has left significant parts of the population insufficiently served, with long travel times — and the traffic in Southern California is not always kind.
There are many other examples, especially in the West and South. Much of Nevada's population does not live near a trauma center; the same is true for Arkansas, Idaho, Maine, New Mexico, South Dakota, western Texas and other states or regions with large rural populations.
The same pattern holds for burn centers; in most of the aforementioned states with one burn center, it is not centrally located — and some of these states do not have the most benign weather conditions, especially when it comes to transporting badly injured patients. A former executive of a tertiary facility in a Western state told me that it receives trauma and burn referrals from 10 states, "weather permitting."
Location, location, location. It does not apply only to real estate appraisals.
The history and current status of trauma and burn care constitute a tangled web indeed. There are many issues that demand to be addressed. Among these are:
Reliable, consistent data are not available. This is not a criticism. Centers open, centers close, the level of care offered by centers changes. Some are designated and/or verified, some are not. Several different organizations are attempting to keep track of it all. Trying to acquire truly current data would make herding ferrets seem really easy. Nonetheless, without good data, it's hard to come up with appropriate solutions.
Not every community should have a tertiary burn or trauma center. Health services research established long ago that volume of patients and mortality are associated; that is, the more you do of a procedure, the better you are at it, and fewer patients develop complications or die. There is a reason states like Alaska and North Dakota do not have these complex specialty centers; they don't have the populations to sustain them. The quality of care offered and the outcomes produced are profoundly important; there is little point in slogging through the snow or being transported by helicopter to a specialty center that doesn't have the necessary expertise.
There are major associated costs. Many years ago, controversial then-Gov. Richard Lamm of Colorado made it clear that he was not going to send National Guard helicopters out on a massive search for a skier who decided to go shushing in off-limits areas. Although I disagreed with Gov. Lamm on many issues, he had a point. People make choices, and if you want to live in the bush in Alaska, then don't expect a trauma center helicopter to be at your beck and call. Transportation costs can be huge.
A former federal health official once said that all that is needed for rural health care is a helicopter. (And people in Washington, D.C., wonder why the rest of us think there is something suspicious in that city's water supply.) Try pulling that off in a three-day blizzard some time, Mr. Official.
And personnel costs arehuge. As Jennifer Ward of the Trauma Center Association of America reminds us, "These centers have to be ready and staffed 24/7, regardless of the number of patients. The fixed costs for a trauma center are quite high. If a center sees two patients a day, or 50, the fixed costs are the same."
The location of trauma and burn centers is not often determined by need. In 2011, Shiara M. Ortiz-Pujols, M.D., and her colleagues at the University of North Carolina published an investigation of the number of burn care clinicians and facilities in the United States, in partnership with the American College of Surgeons (Shiara M. Ortiz-Pujols et al., "Burn Care: Are There Sufficient Providers and Facilities?" an issue brief by the American College of Surgeons Health Policy Research Institute, November 2011, Issue 9). They concluded that the supply of both burn centers and surgeons was at risk.
Their analysis found that "fewer burn care centers and potentially fewer burn care surgeons, compounded by the need to reduce health care spending, make ensuring appropriate burn care an increasingly difficult task … As the trauma [care] model has evolved, studies have shown that the regionalized system improved patient access and care quality and lowered costs. Understanding the number and geographic distribution of burn centers is a first step toward determining whether regionalizing burn care might share similar benefits."
The problem, of course, is that in the minds of many health care leaders, regionalization is a code word for planning, the very notion of which gives most of them a rash. There is good reason for that. The 1974 federal health planning law, which may have been conceived as a way to rationalize health care and actually make more resources available, morphed in the regulation-writing process into a futile exercise in cost-containment, leaving hospitals buried in certificate-of-need requirements and other paperwork and, in the end, the providers usually prevailed anyway. Most people in health care probably breathed a sigh of relief when the law died a quiet death.
Nonetheless, when it comes to these expensive, critically needed services, their location and level of expertise would be best determined by something in addition to pure market forces, which do not always dictate the most humane or rational decisions.
A single hospital, or even a health system, should not have to take this task on by itself. Some states, as mentioned, have established dedicated funding streams for trauma and burn care. In Texas, for example, the revenue comes from motor vehicle violations, especially speeding tickets, which seems very appropriate indeed. And advocates for both burn and trauma services have sought federal help although, for the most part, their proposals have not been funded.
The ACA has increased insurance coverage by — according to the feds, and I'm not going to get into the debate over this — more than 16 million people, but that still leaves more than 30 million uninsured, and many of them are young, low-income members of minority groups. These are the same people who are disproportionately likely to suffer trauma and burns. Those providers who care for them are still losing massive amounts of money, and some can ill afford it.
Furthermore, in the rush to avoid cost increases in the years after the ACA was passed, some employers and insurers started offering plans that did not cover hospital care. (I mean, really.)The Obama administration eventually outlawed this type of coverage — if you want to call it that — but there are likely people out there who don't realize that when it comes to inpatient care, let alone trauma and burn treatment, they're on their own.
Is dedicated funding from the federal government, state government or municipalities possible? It already exists in some places. Trunkey says, "It's doable. There are other problems in the health care system, and the people associated with those issues will whine if burn and trauma care get the funding. But it's doable."
That will take a great deal more political will than is currently available.
It's Everyone's Problem
Although only a minority of American hospitals are home to trauma and burn centers, what they do matters. A lot. Trauma and burns affect all of us. According to the American Trauma Society and the National Trauma Institute, as reported by the University Health System of Bexar County, Texas:
• Trauma is the leading cause of death for people ages 1 to 44.
• Trauma is the leading cause of death for children in the United States.
• Trauma kills more people younger than 44 than cancer, heart disease or AIDS.
• At least 150,000 people die in the United States annually as the result of trauma.
• Trauma accounts for 37 million emergency department visits and 2.6 hospital admissions per year.
• Annual U.S. trauma costs are estimated at $700 billion.
• One of every three Americans is directly or indirectly affected by trauma.
We can do better than this. Perhaps we deserve the American College of Emergency Physicians' D+ rating for how we handle emergency care. But we really can do better, and let's hope, complex as these issues are, that we will. There's a lot to lose and a lot to win. As Ahrenholz says, "So many burn and trauma patients are young and have many productive years ahead of them, and if we want to maximize quality of life for Americans, it would be money well spent. The joy of treating burn and trauma patients is that many of them get better."
This article is dedicated, with affection, to the memory of Roberta Laffey of Madison, Wis., who died last year after a courageous two-year fight against the complications of a traumatic brain injury sustained when she slipped on the ice near her home and hit her head.
Copyright © 2015 by Emily Friedman. All rights reserved.