American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Part 4: America’s Incomplete Trauma System

The goal of getting the “right patient to the right place at the right time” is embodied by the inclusive, regionalized trauma system. This system is driven by the knowledge that surviving traumatic injury depends on reaching the appropriate level of definitive care as soon as possible.

Since 1966, when the National Research Council called for the development of regionalized trauma systems, this approach to trauma care has been partially implemented in most states around the nation.1 Today, injured patients have a greater chance of surviving than any time before; in many parts of the country, trauma patients receive world-class care.

But significant gaps remain: One in three Americans live in a region without a complete trauma system. When an injury occurs, oftentimes people nearby don’t know what to do beyond calling 911, and some first responders such as police officers may lack medical training. Some patients may not be sent to the most appropriate trauma center for the severity of their injuries or may live in rural areas with limited trauma center access, introducing critical delays in care. These gaps impede a successful recovery and can cost lives.2

America’s trauma system has achieved dramatic advances over the past 50 years. But that progress hasn’t reached every injured patient yet. In our fourth story, we outline the gaps that need to be closed in the system. Then in our fifth story, we will discuss steps that national trauma leaders are taking to close those gaps and complete the nation’s trauma system.

Delivering Immediate Aid to the Injured

In medicine, it’s called the “golden hour”—getting the trauma patient to definitive care within an hour of the injury for the best chance of survival before shock causes damage to organs. But some injured people don’t have an hour: for instance, those who are bleeding heavily may have just minutes to live unless the bleeding is slowed or stopped.3 Hemorrhage is responsible for 30 to 40 percent of trauma deaths, a third to half of which occur before the injured person makes it to a trauma center.4

“There is no such thing as a ‘Golden Hour’ for a patient with severe blood loss,” said Mark Gestring, MD, FACS, member of the American College of Surgeons Committee on Trauma (ACS COT) and Chair of its Emergency Medical Services (EMS) Committee, who said uncontrolled bleeding is the leading cause of preventable trauma death.

That’s why there is growing recognition of the importance of “turning bystanders into immediate responders”—those who happen to be near the patient when the injury occurs. An immediate responder who has been trained in basic bleeding control with a tourniquet, or wound packing supplies, may mean the difference between life and death before EMS personnel arrive.

But few civilians today know what to do to help someone who is severely injured, even amid the growing number of multicasualty events that resemble battlefield scenes: Sandy Hook, Paris, and San Bernardino, to name a few. Between 2000 and 2013, there were 1,043 casualties from mass shootings in the United States, according to the Federal Bureau of Investigation.5

“These incidents have really changed the playing field for trauma centers—making it much more like a military scene,” Dr. Gestring said.

The American College of Surgeons, in partnership with President Obama’s administration and Federal agencies, created Stop the Bleed<sup>®</sup> to train citizens in techniques to control bleeding. As of August 2017 more than 6,000 instructors in all 50 states have received training.

Applying military trauma care practices to domestic mass casualty incidents is “relevant and timely,” Dr. Gestring said. An example is the successful medical response to the 2013 Boston Marathon bombing where there were more than 260 casualties, many victims with injury patterns similar to blast injuries seen in Afghanistan and Iraq.6 Applying tourniquets at the scene in Boston was a paradigm shift in civilian use of pre-hospital tourniquets based on the military’s recent wartime experience.7

In recent years, the military has had great success in extending life-saving care far into the field.8 Since 2009, all soldiers in combat zones, not just medics, are issued tourniquets and other basic emergency medical supplies, and are given training to use them.9 From 2005 to 2011, an estimated 1,000 to 2,000 lives were saved by widespread tourniquet distribution to deploying U.S. military service members.10,11

In the wake of the 2012 mass shooting at Sandy Hook Elementary School in Newtown, CT, preventing a severe bleeding death in victims who have a survivable injury has been the focus of work of the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooters Events, convened by the American College of Surgeons. The committee’s deliberations are known as the “Hartford Consensus” because the group’s inaugural meeting occurred in Hartford, CT. The committee’s first “Hartford Consensus” report strongly recommended the public be trained in bleeding control methods.12

In October 2015, ACS, in partnership with President Obama’s administration and Federal Agencies including the Department of Defense, launched the Stop the Bleed® campaign. It has since been supported by more than 40 partner organizations that have helped train the public in controlling bleeding, distributed bleeding control kits, and promoted the initiative in materials and social media.13,14 More than 6,000 instructors from all 50 states have been trained by ACS COT experts, Dr. Gestring said. The goal is to train every U.S. citizen in these life-saving skills and to have bleeding control equipment available next to every public access defibrillator so there is much more work to be done.

Reducing EMS Variability

While half of trauma deaths occur outside of the hospital, emergency medical services, which provide vital life-saving care, have not been considered an essential component of the health system in some areas of the country. Variability in response times, training, and communication with hospitals and 911 systems are among the challenges that contribute to lives lost.

Trauma systems depend on EMS, including 911 call systems, ambulances, and skilled emergency personnel to provide the critical link between an injury event and definitive care. Within the ideal trauma system, EMS will stabilize the injured patient and get them to the appropriate level of care as quickly as possible for further intervention.15

Yet today there is a wide range of skills, consistency, and organization among EMS systems in the United States. There are 21,283 credentialed EMS agencies—a mix of private, public, and volunteer systems that often operate independently and sometimes at odds with each other.16 These activities range from individual “home rule” ambulance services to coordinated regional or county-based systems. The ambulance services used may be from the fire department, a separate municipal agency, or a private organization.17 These systems function under varying medical protocols and may have limited access to advanced life support interventions.

As the nation’s health system evolves, EMS has not been treated as an essential component of medical care:

  • There continues to be a lack of EMS quality measures, patient data, or standards of care.
  • No national response time standards exist, and response time targets range from eight minutes to up to 12 to 15 minutes.18
  • There may be poor cooperation or communication within or between systems when the most appropriate trauma center for the patient is in a different health system than the EMS provider. This could lead to delays in inter-hospital transfer.19
  • Guidelines established by ACS and the U.S. Centers for Disease Control and Prevention (CDC) to get the patient to the right level of care are not followed by all EMS systems.20–22 In some regions, as many as one in three severely injured patients are not transferred to a Level I or II center.23 In 2011, less than one in three states indicated that they had implemented some or all of the CDC’s 2006 guidelines.24
  • A commonly used “fee-for-transport” reimbursement model that pays by the mile and by the level of service provided en route ignores the critical care delivered by EMS providers at the point of injury and encourages unnecessary transports. In fact, up to 61 percent of EMS transports to emergency departments are medically unnecessary, which adds costs to the health care system, burdens hospital-based providers, and hinders attempts to deliver the appropriate level of care to the patient. 25–27

As a result of this patchwork of EMS systems, survival can vary as great as twofold among severe trauma patients treated by EMS in various communities across North America.28,29 This variation also makes it difficult to unify the many EMS stakeholders.

Links Across Regional Trauma Systems

An inclusive trauma care system incorporates every community health care facility to match the needs of the injured to the appropriate levels of care, ensuring that the most severely injured have access to the highest level of care while minimizing duplication of expensive resources across the system.30 Inclusive, regionalized trauma systems have been shown to be cost effective, save lives and improve the lives of survivors.31

Central to any such trauma system is the proper number and location of large, resource-rich trauma centers (Levels I and II). There are nearly 2,000 trauma centers in the United States: 213 Level I, 313 Level II, 470 Level III, and 916 Level IV or V centers.32 To help build and strengthen trauma systems nationally, the ACS COT offers trauma system consultation and has developed standards for verification of trauma centers at each level of care. 33

The continuum of care for trauma patients depends on timely, structured, cooperation and communication across all providers, hospitals and EMS agencies. Breaks in the continuum “almost certainly contribute to excess morbidity and mortality.”34

Yet today, trauma systems do not always communicate and work smoothly with other trauma systems in the region, especially across state lines.Further, many areas across the country have not implemented the essential elements of a trauma system,and trauma centers may not comply with best practices established by the ACS Committee on Trauma, and other organizations, leading to inconsistent quality of trauma care. A study of 55 trauma centers found that only one was compliant with 32 practice protocols, while half were compliant with 14 of the 32. Variable compliance leads to variable patient outcomes.35 If every system adopted the CDC’s triage guidelines, for example, the number of patients who are incorrectly triaged would be reduced by at least 12 percent.36

The uneven distribution of trauma centers across the country further contributes to inconsistency in patient outcomes. Injured patients are more likely to die if they do not have access to an appropriate level of trauma care within an hour of their injury.37 Some areas have few or no Level I and II trauma centers, and some urban areas have too many. This means that where you are injured may determine whether or not you survive.

“In many regions, trauma centers are not distributed based on the needs of the population, they are established based on hospital-driven priorities, often including profitability,” said Robert J. Winchell, MD, FACS, Chair, ACS Trauma Systems Evaluation and Planning Committee. “As a result, some areas are left completely uncovered, while other regions are over-served. While rural areas are more likely to lack a trauma center, even some of the nation’s largest cities do not have enough trauma centers to care for seriously injured patients, especially in low-income neighborhoods.”

Robert J. Winchell, MD, FACS, Chair, ACS Trauma Systems Evaluation and Planning Committee, speaks to fellow trauma leaders about need-based distribution of trauma centers. Some regions of the country, including some of the nation’s large urban centers, lack an adequate number of trauma centers.

Just 24 percent of those who live in rural areas have access to a Level I or II trauma center within one hour, while 86 percent of suburban and 95 percent of urban residents have timely access.38 Too many trauma centers can also impact the quality of care: Since higher patient volumes generally correlate with improved quality of care, too many trauma centers means that at least some of the centers won’t have sufficient patient volumes to stay on top of their game.39 One study estimates that nearly 20,000 Americans could be saved each year if all trauma centers achieved outcomes similar to those at the highest-performing centers.40

These gaps are particularly troubling given that trauma systems are the backbone of the disaster response.

Responding to a mass casualty event or national disaster requires a coordinated effort between many local, state and national emergency service providers. In many states, however, EMS and emergency preparedness programs are housed in separate agencies, operate on separate state and federal funding streams, and may rarely communicate.41 Nor is it always clearly established who has command and control during a mass casualty event.

“A strong trauma system that functions well on a daily basis is the best preparation for mass casualty events,” said Dr. Winchell. “Trauma systems should be prioritized as part of readiness, and must be tightly integrated into disaster and crisis response, but this is not always the case.”

Improving the Quality of Trauma Care

A regional trauma system takes a three-pronged approach to improving the quality of care for injured patients: Identifying the problem based on data, developing and implementing an intervention, and evaluating the outcome of the intervention. Data on the processes and outcomes of care within a system are critical to ensuring that the system evolves and improves over time.

Trauma registries, such as the ACS National Trauma Data Bank (NTDB), and quality programs such as the ACS Trauma Quality Improvement Program (TQIP)42, are used to measure trauma outcomes and system performance, inform trauma research, and drive the development of new best practices.

Although ACS has established a process for performance improvement across trauma centers, there is no equivalent national program yet for prehospital care. Generally, EMS systems follow medical protocols that may be local, countywide, regional, or statewide.43–47 Recently, prehospital data have been aggregated into the National EMS Database, although submission is voluntary and there currently is no way for EMS agencies to benchmark their institutional performance.

Also, until state-level EMS data are linked with trauma registries, it is difficult to track the injured patient across stages of trauma care (especially if they are transferred), or determine time from 911 calls to arrival at appropriate trauma centers and transfer times.

“Amazon can track a package from the moment it leaves its warehouse to the moment it arrives at your house,” said Eileen Bulger, MD, FACS, member of the Executive Committee of the ACS COT. “But we currently cannot track a patient from their point of injury until they return home.”

Data are essential to continuing to improve care for all trauma patients, said Eileen Bulger, MD, FACS, member of the Executive Committee of the ACS COT. Currently, data are not collected across the trauma system, from the point of injury to EMS to the hospital and after.

Perhaps the most significant effort to establish evidence-based measures for prehospital care is EMS Compass, an ongoing initiative of the National Highway Traffic Safety Administration Office. There also is hope that EMS Compass could enable benchmarking of EMS performance, serving as the first step toward the creation of a program similar to TQIP for comparing and assessing EMS systems.

Data are critical to research, which is the empirical feedback loop that validates and sustains continuous improvement in trauma care. Research findings help define best practices and can alter the course of system development. Research activity is a required capability of high-level trauma centers.48 As a result, there has been much more trauma research and scholarship as registries have been built up.

But much more must be done.

Injury accounts for nearly 10 percent of total disability-adjusted life years lost in the U.S. each year and is the leading cause of death for Americans under the age of 46. Injuries cost the U.S. $671 billion in 2013. Even so, injury receives only about one percent, or $399 million, of the National Institutes of Health’s $30 billion biomedical research budget. 49 For example, from 1992 to 2016, the U.S. spent nearly $3.3 billion on breast cancer research but only $15 million on trauma research. This disparity indicates a lack of patient advocacy and public understanding of trauma and the role of research in addressing gaps in optimal trauma care.50

“We can improve care for injured patients by attending to them immediately, stabilizing and getting them to the most appropriate level of care, strengthening our trauma systems, and improving the quality of trauma care through data and research that can lead to improved practices and higher standards,” Ronald M. Stewart, MD, FACS, Chair, ACS Committee on Trauma, said. “Traumatic injury is the leading health crisis facing our children and our uniformed service personnel in combat, and we must act now to improve care, save more lives, and ensure our national security and preparedness.”


Coming Next: Now is the Time to Complete the Nation’s Trauma System
For 50 years, the trauma community, government agencies and partner organizations have worked together to establish the nation’s trauma system, leading to world-class care in many areas. Today, trauma leaders are working together to complete the nation’s trauma system. In our next story, we will outline steps being taken to fill in the remaining gaps to achieve the goal of zero preventable deaths and disability from traumatic injury.


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  2. The trauma system extends from before the patient gets injured to their rehabilitation after they leave the hospital and reintegration into society. To be sure, prevention and rehabilitation are two cornerstones of a successful modern trauma system that deserve and, to some extent have received, attention and resources . This series of reports is focusing on what happens immediately when the patient is injured to the quality of the definitive care that is ultimately delivered to them.
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