the appropriate trauma center, while the children’s hospital provides trauma care to all seriously injured children below the age of 14. Serious burn cases are taken to the University of California-San Diego Burn Center. The county is considering regionalization for other conditions, such as stroke and heart attack, based on the trauma model. The system includes the designation of regional trauma centers, designation of base hospitals to provide medical direction to EMS personnel, establishment of regional medical policies and procedures, and licensure of EMS.

Accountability

Accountability is driven by a quality improvement program in which a medical audit committee meets monthly to review systemwide patient deaths and complications. The committee includes trauma directors; trauma nurse managers; the county medical examiner; the chief of EMS; and representatives of key specialty organizations, including orthopedic surgeons and neurosurgeons, as well as a representative for nondesignated facilities. A separate prehospital audit committee that includes ED physicians and prehospital providers also meets monthly and discusses any relevant prehospital issues.

DEMONSTRATING FUTURE MODELS

States and regions face a variety of situations, and no one approach to building emergency and trauma care systems will achieve the goals discussed in this chapter. There is, for example, substantial variation across states and regions in the level of development of trauma systems; the effectiveness of state EMS offices and regional EMS councils; and the degree of coordination and integration among fire departments, EMS, hospitals, trauma centers, and emergency management. The baseline conditions and needs also vary. For example, rural areas face very different problems from those of urban areas, and an approach that works for one may be counterproductive for the other.

In addition to these varying needs and conditions, the problems involved are too complex for the committee to prescribe an a priori solution. A number of different avenues should be explored and evaluated to determine what does and does not work. Over time and over a number of controlled initiatives, such a process should yield important insights about what works and under what conditions. These insights can provide best-practice models that can be widely adopted to advance the nation toward the committee’s vision.

The process described here is one that can be supported effectively through federal demonstration projects. Such an approach can provide



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