Most Americans assume that if they're in a car wreck or another severe injury befalls them, an ambulance will arrive quickly and whisk them away to a hospital that can handle their particular condition. But in many places that assumption would be wrong.

Nearly 45 million Americans do not have access to a Level I or Level II trauma center within the "golden hour" after they are injured, according to 2009 Centers for Disease Control and Prevention data. Although most injuries can be handled at a local emergency department, treatment of severe injuries at a Level I trauma center lowers the patient's risk of death by 25 percent.

To close the gaps, many states either have developed statewide trauma systems over the past decade or are in the process of creating them. However, "the overall landscape across the United States is islands of excellence surrounded by large portions of our country where injured patients don't have access to a trauma system," says A. Brent Eastman, M.D., chief medical officer of Scripps Health in San Diego and chair of trauma at Scripps Memorial Hospital La Jolla. Even states with well-developed systems sometimes have holes in trauma center access.

The goal, Eastman says, is to have systems in place so that no matter where a person is injured in the United States, he or she will be assured of "expeditious transport to the appropriate level of care commensurate with the injury."

Building an inclusive system

In an ideal trauma system, all acute care facilities participate and hospitals caring for patients with anything beyond minor injuries should have a trauma program designation. All acute care hospitals should participate in a state trauma registry, follow agreed-upon patient transfer and care guidelines, and engage in continuous quality improvement. Emergency medical services, fire departments and police are involved in creating the system and participate in it. And the system addresses all types of care: trauma prevention, pre-hospital care, acute care and rehabilitation.

Trauma experts emphasize the importance of an inclusive trauma system. When San Diego County first established its trauma system in the 1980s, it made the mistake of creating an exclusive system in which all injured patients were taken to a Level I or II trauma center, notes Eastman, one of the system's co-founders.

The Level I and II centers quickly were overwhelmed by patients who could have been cared for properly elsewhere, Eastman says. About 85 percent of injured patients can be treated at their local hospitals as long as that facility is committed to trauma care, he says.

Community hospitals with strong EDs suddenly became "have-nots," losing emergency patients that they were equipped to handle to trauma centers, Eastman says. Also, patients who lived far from the trauma centers were taken away from their family and friend support systems.

In an inclusive system, all hospitals participate to the extent that their resources and capabilities allow. But even when creating an inclusive system, the politics can be tricky to navigate. Some hospitals inevitably will see fewer serious trauma patients once the system is mapped out so that patients are taken to the hospital that can best meet their medical needs, as opposed to the nearest hospital regardless of its capacity to care for their injuries. In some places, health care systems with several hospitals that are used to transferring trauma patients within their networks suddenly will have to transfer severe trauma patients outside their networks.

One way to ease tension is to adopt the CDC's field triage protocols that were developed in partnership with the American College of Surgeons and the National Highway Traffic Safety Administration, says Cecile D'Huyvetter, R.N., trauma program director at Gundersen Lutheran, La Crosse, Wis., a Level II trauma center. Using these protocols, EMS professionals identify the severity and type of injury, and then transport the patient to the facility that is best-equipped to meet his or her needs.

It also helps to keep the focus on what's right for the patient, D'Huyvetter says. "During many discussions at state meetings, when things got out of control, that was brought back to the forefront and redirected the conversation."

Every hospital has a place

Making sure hospitals across the trauma care spectrum have a role makes the transition easier as well. Not every hospital can or should be a Level I or II trauma center. Those with a Level III designation or below are able to continue to care for less seriously injured patients and stabilize and transfer the most severely injured to the higher-level centers in their regions.

"Every hospital should feel part of a trauma system, actually be part of a trauma system, no matter what its status is," says Greg Bishop, president and founder of the trauma care consulting firm Bishop+Associates in Irvine, Calif. "They're going to get trauma patients and, in some cases, patients who are so severely injured that they're on the verge of dying. In other cases, patients show up on their doorstep who wind up having more serious injuries than they were aware of."

Even in places without a formal trauma system, non-designated hospitals with emergency departments should have transfer agreements and relationships with the big trauma centers in their regions to take the guesswork out of which patients need to be transferred and where to send them, says John Osborn, administrator of the Mayo Clinic Trauma Centers. They also can work together on shared practice guidelines. The Mayo Clinic, part of Minnesota's state trauma system, is collaborating with community hospitals to make sure patients with open fractures get antibiotics in a timely fashion, regardless of whether they need to be transferred, Osborn says.

When Wisconsin started its inclusive trauma system a little more than a decade ago, hospitals were given the trauma center designation criteria and asked to self-assess, D'Huyvetter says. Many settled on Level III and IV designations, partly because they lacked the surgical coverage needed for a higher designation. Now, some Level IV hospitals are striving for Level III status because of community need. The state uses the American College of Surgeons verification program for Level I and II centers and its own designation program for Level III and IV hospitals.

The first step for any hospital seeking its first designation or striving to increase its designation level is to review the criteria used in its state. Then it must consider whether it has sufficient trauma patient volume, what its resources are, if it can recruit and retain the necessary specialists, whether it can afford those physicians, and if it has the support of the current medical staff.

Having enough patient volume is important not only to make sure the service line is viable, but also to ensure care quality, D'Huyvetter says. "To stay good at trauma care, you have to see it."

High costs, iffy payments

Cost and payment are huge factors in a hospital's decision to obtain or advance its trauma designation. "The problem that a trauma center faces is that it costs money every day to have my trauma center, whether or not I see a patient, because I need to pay to have the surgeons on call at night and to have an OR ready around the clock and have specialists available to respond to patients with no real idea of what tomorrow's volume is going to be," Osborn says. "So your ability to plan for your reimbursement and, therefore, budget is pretty limited."

Hospitals can charge insurers an activation fee for bringing the trauma team together in cases in which EMS has notified the ED that a critically injured patient is on the way. To bill for activation, the hospital must have trauma center designation from the state or American College of Surgeons verification.

"The problem is [that] almost all hospitals will activate their trauma team based on suspicion of injury," Osborn says. "Based on your mechanism of injury — you were ejected from your vehicle or your vital signs hit certain parameters — we're going to activate the team. Everybody drops what they're doing and runs to the ER, and we've called physicians in from home, potentially, and disrupted the ORs. But it's not uncommon that you end up not being as severely injured as you might have been given those circumstances."

In such cases, activation payment isn't guaranteed. For example, Medicare won't pay for trauma activation if the patient turns out not to have a critical injury, Osborn says.

Government's role

Uncompensated care also is a major problem. About 15 percent of trauma patients are uninsured, according to the Trauma Center Association of America.

"Not only are you paying up front to make sure that you've got a specialist there, but you're also providing an expensive service and not being reimbursed," Osborn says. "At a lot of urban centers that are what you would consider the 'knife and gun club,' where you've got penetrating injuries, you're typically not dealing with an insured population."

The financial pressures and reimbursement picture have given trauma centers the reputation of being unprofitable. Between 1990 and 2005, about 30 percent of trauma centers closed, largely for financial reasons, according to an October 2011 article published in Health Affairs.

The result is that in some areas, where a need for a Level I or II trauma center exists, hospitals are reluctant to make the investment, Osborn says.

The trauma center community is lobbying at the state and federal levels for improved trauma center reimbursement and funding. It's also advocating for revenue to cover the administrative costs of trauma systems, such as trauma registries, regional meetings and educational programs for hospitals and first responders.

Some states have created revenue streams, for example, by using a portion of the fines for such safety-related infractions as drunk driving to fund trauma care.

Because many states can't afford the investment and because trauma is a national public health problem, trauma centers also are pushing for the federal government to actually appropriate the funds authorized in the Affordable Care Act. The law calls for $24 million in annual grants through 2014 to help states develop regionalized trauma systems. It also authorizes $100 million in annual grants through 2015 to help states provide trauma centers with funds to stabilize their finances and support physician trauma care payment.

Injuries are the leading cause of death for Americans younger than 45, but most Americans don't recognize injury as the public health problem that it is, trauma experts say. "Everybody worries about the scourge of cancer and these sorts of things, but everybody takes for granted that if they get in a car accident, an ambulance will pick them up and hospitals will take care of them," Osborn says. To make that perception a reality, the federal government needs to invest in ensuring financially viable trauma care, he adds.

The 'halo effect'

Despite the uncertainty, new trauma centers are being developed, largely because of state efforts to create trauma systems, Bishop says. Hospitals in suburban areas where the population is growing and where patients might welcome an alternative to inner-city trauma centers could be in a good position to become successful trauma centers, he suggests.

Trauma isn't a guaranteed money loser, Bishop adds. "A trauma center with a decent volume and a good payer mix should be making money," he says. "They tend not to make lots of money, and they tend not to lose a lot of money, because they just can't afford to."

He encourages hospitals to consider what he calls the "halo effect," the benefits that becoming a trauma center bring to the hospital as a whole. One advantage is that trauma patients often come back to the hospital for other services. Also, seeking Level I or II status strengthens the surgical and orthopedics service lines and establishes "24/7 readiness for everything, resulting in a true regional hospital," Bishop says.

"The No. 1 reason hospital CEOs like their trauma centers has nothing to do with money or market share; it's that it makes them a better hospital," Bishop adds. A big reason is the emphasis the verification process puts on collaboration and continuous quality improvement.

When Wisconsin created its trauma system, a lot of time was spent educating hospitals on how to conduct performance improvement, D'Huyvetter says. Subsequent three-year trauma center reviews have shown that the performance improvement mentality spreads from trauma care throughout the hospital, she says. For example, most severely injured patients are put on ventilators, so Gundersen adopted pneumonia prevention protocols for those trauma patients. Now that's the standard of care for all patients.

As a Level II center, Gundersen reviews 136 system and clinical filters on its trauma patients, D'Huyvetter says. For example, if a trauma surgeon isn't present within 15 minutes of patient arrival, the case gets reviewed. The hospital also reviews EMS scene times. "If an ambulance sits at a scene for greater than 20 minutes, we need to know why."

Winning over your doctors

Hospitals that decide to go the trauma center route often face a major hurdle in meeting surgical coverage criteria. The problem is twofold. The existing medical staff don't want to serve on call, and recruiting surgeons is difficult because of the physician shortage.

Initially, the medical staff "are just going to be fearful of the unknown," Bishop says. "All they remember is when they were residents and getting up for those trauma cases. It was very difficult, and now they have kids. They don't want to do that anymore."

Surgeons worry that their practices will suffer. They'll wind up staying up all night caring for a trauma patient and will have to cancel surgeries the next day, or they'll be called away from the clinic during the day to handle injuries.

"The medical staff will tell you all the reasons they shouldn't be a trauma center couched in the difficulty they're having in treating trauma today," Bishop says. "If you look into it, it's not a coordinated care process; it's very problematic."

Part of the solution is to educate the medical staff about what's going on in the hospital now in trauma care in terms of volume, severity and payer mix. Listen to the medical staff's concerns about trauma operation.

"The first step is always to say, 'OK, let's start improving trauma care today,'" Bishop says. "You do whatever you can on the front end to bring in the medical staff in a very collaborative way and provide them information so they can react based on the reality vs. fears."

In recent years, regional trauma centers have hired acute care surgeons to take the pressure off the regular medical staff. This makes taking on higher-level trauma certification easier, especially in terms of winning over the existing medical staff, Bishop says.

Finding enough surgeons

Acute care surgery, a relatively new field, combines trauma surgery, emergency surgery and surgical critical care. Acute care surgeons are employed by the hospital, work set shifts and don't have private practices. They form the core of trauma care, but also perform emergency and acute care surgery. For example, if a patient with appendicitis arrives at the ED, the acute care surgeon will perform the appendectomy. This saves the general surgeon from having to leave his or her clinic to do the operation.

But because the field is new and the fellowship programs are young, there aren't enough acute care surgeons to go around, Bishop says. That, combined with the growing shortage of surgeons in general, "is going to be a real challenge to trauma systems," he adds.

Aggravating the situation is a maldistribution of surgeons, marked by a dearth of surgeons in rural areas, says Eastman, who is president-elect of the American College of Surgeons. A study Eastman co-authored found that in areas without surgeons, death rates from motor vehicle crashes are much higher than those in areas with surgeons.

The surgical community is advocating for increased federal funding to train more surgeons. "We have to create the incentives to train more surgeons who … have abilities to care for injured patients," Eastman says.

Producing enough of these doctors will take a long time. "We're going to have to have physician extenders to make it possible for one surgeon to take care of more patients, and we're going to have to rely on new technology, such as videoconferencing, to help bridge the gap of the shortage of physicians," he says.

Geri Aston is an H&HN contributing editor.

Executive Corner

Lead the way

To get the ball rolling on creating a regional trauma system, hospital leadership is essential, and not just from the C-suite, says A. Brent Eastman, M.D., a co-founder of San Diego County's trauma system, one of the oldest in the nation. "You've got to have a surgical champion, somebody who understands trauma surgery," he says. "Without physician leadership, I've never seen a system succeed."

Gather data

A major catalyst for San Diego County's system was a 1982 Trauma Care Needs Assessment Study. "It was done, in many people's minds, to show we did not need a trauma system," Eastman says. It found the opposite. The study — a retrospective review of autopsies on all injured patients in the region — found a potentially preventable death rate of "an astonishing 22 percent," he says. "I can guarantee CEOs that if they do a preventable death study, they'll find a rate somewhere in the range of 20 to 25 percent. That's not anything that anybody could live with."

Government leadership

A trauma system can't be developed without a lead agency, usually part of the county or state government. This agency, empowered through legislation, should have the authority, responsibility and resources to lead the planning, development, operation and evaluation of the trauma system. The hospital CEO could determine the logical lead agency and then reach out to one of its officials about the need for a trauma system. "You need a lead agency, which has the political authority and courage to say, 'We are going to create a regionalized trauma system,'" Eastman says. "It took our board of supervisors having the political will to form the trauma system."

Bring in the experts

The American College of Surgeons produced a guide that explains what a regional trauma system is and the optimal elements. The guide is a valuable tool for a hospital CEO interested in spurring trauma system formation, Eastman says. The college also offers a consultation service in which a team of experts evaluates materials submitted by the lead agency and makes a site visit. The team interviews hospital administrators, surgeons, nurses, pre-hospital providers and first responders. It doesn't determine whether the effort to build a system passes or fails, but offers recommendations on what more is needed to develop an effective trauma system.