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Regionalized Trauma Care: Past, Present, and Future

A. Brent Eastman, a founder of the San Diego trauma system and a member of the 2006 Institute of Medicine (IOM) committee on the Future of Emergency Care in the United States Health System, chaired the workshop’s first session. The session examined past experience with regional trauma systems in the United States, and what lessons they might offer to future regionalization efforts in emergency care. Eastman noted that true trauma system integration means that no matter where in the United States a trauma occurs, the patient is assured expeditious transport to the level of care that is commensurate with their injury, whether that is 10 minutes or 10 hours away. He argued that we should constantly remind ourselves this is an inclusive system, representing an entire continuum of care, not only the Level I trauma centers where the most critical patients go. He emphasized that Level I centers are an important part of the continuum, but they are only a part. “Regionalization is not synonymous with centralization,” he said.

Each of the four presenters offered a 5-minute opening statement, accompanied by a single PowerPoint slide that summarized their key takeaway points. Following these presentations, the session chair opened the floor for an extended and in-depth discussion with the audience.

EMERGENCY CARE REGIONALIZATION IN THE 1970s

The session’s first speaker was David Boyd, who led the U.S. government’s drive toward regionalized emergency care during the 1970s as the national director of the Office of Emergency Medical Services Systems within



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1 Regionalized Trauma Care: Past, Present, and Future A. Brent Eastman, a founder of the San Diego trauma system and a member of the 2006 Institute of Medicine (IOM) committee on the Future of Emergency Care in the United States Health System, chaired the work- shop’s first session. The session examined past experience with regional trauma systems in the United States, and what lessons they might offer to future regionalization efforts in emergency care. Eastman noted that true trauma system integration means that no matter where in the United States a trauma occurs, the patient is assured expeditious transport to the level of care that is commensurate with their injury, whether that is 10 minutes or 10 hours away. He argued that we should constantly remind ourselves this is an inclusive system, representing an entire continuum of care, not only the Level I trauma centers where the most critical patients go. He empha- sized that Level I centers are an important part of the continuum, but they are only a part. “Regionalization is not synonymous with centralization,” he said. Each of the four presenters offered a 5-minute opening statement, accompanied by a single PowerPoint slide that summarized their key take- away points. Following these presentations, the session chair opened the floor for an extended and in-depth discussion with the audience. EMERGENCY CARE REGIONALIZATION IN THE 1970s The session’s first speaker was David Boyd, who led the U.S. govern- ment’s drive toward regionalized emergency care during the 1970s as the national director of the Office of Emergency Medical Services Systems within 

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 REGIONALIZING EMERGENCY CARE the Department of Health, Education, and Welfare (later Health and Human Services). This office was created by the EMS Systems Act of 1973. Boyd started by saying, “Regionalization is a verb. It’s what you do, [and] how you do it.” He described his effort to organize a coordinated sys- tem first at the state level in Illinois. The effort brought public health, hospi- tals, surgical personnel and all the components of the emergency and trauma care system together under an organized plan. The state established a lead agency within the Department of Health which aided in breaking the state down into regional groups and organizing the available hospital capacity. However, he said there were many emergency care-related functions in public health, transportation, and other parts of the government that were not under lead agency control, but should have been. He stressed that a lead agency is essential for coordinating an effort as complex as this. Describing the activities of the federal lead agency at DHEW-HHS in the 1970s, Boyd noted that regional systems are not all the same across the country. His department determined at that time there are at least three basic socio-geographic regional models. The first is an urban-suburban model, including cities such as New York and Chicago. These regions, he said, are medically affluent—they have organized, all advanced life support (ALS) emergency medical services systems and, often, too many hospitals competing for special designations. Second, there is a rural-metropolitan model. Boyd said this model applies virtually anywhere there are trees—from the west coast to east coast. It includes towns such as Peoria, Illinois; Spokane, Washington; and Memphis, Tennessee—towns that have adequate medical capability in their centers (if they are able to consolidate and organize it), and rural areas nearby. The third model, wilderness-metropolitan, “is found in large, open areas where there are no trees,” Boyd said. This includes parts of New Mexico, Texas, and Alaska where, he said, “you are really talking about a very bleak rural system.” These are areas with long transport distances and essentially no specialty care. Boyd said that these regional divisions were used in tailoring the dif- ferent types of technical assistance offered by the federal government to regional areas. The categories also became part of the federal funding mechanism and the grant process. Boyd said that regional context and socio- geographic mix were important in differentiating the kinds of solutions that might work in a given area. THE STATES’ PERSPECTIVE The panel’s second speaker was Bob Bailey, former director of the North Carolina State Emergency Medical Services (EMS) program and past presi-

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 REGIONALIZED TRAUMA CARE dent of the National Association of State EMS Directors. Bailey said that he had been on the receiving end of the federal program undertaken in the 1970s. He acknowledged that the federal initiative was able to jump-start a tremendous number of EMS trauma systems across the country. However, he said for a time federal funding was going directly to regions, which in some cases created conflicts with states that held different views on how best to develop systems. When the federal grant program ended, some regional systems were not able to survive. Others survived but on a much smaller scale than before. Bailey said systems that had done their homework were able to sustain themselves. However, he added, many state programs suffered from the loss of the federal monies because the resources for personnel and other system components were no longer there. Bailey’s takeaway points were that (1) states must play a key role in establishing any regional system in order to ensure consistency and sustain- ability; (2) states should provide legal authority for regions to exist. This provides them with more clout and a greater ability to raise additional money; (3) states should facilitate, coordinate, and designate regional sys- tems and make sure that quality assurance improvement programs are in place and functioning; and (4) there has to be sufficient funding in place to allow states to do their job and to ensure regional sustainability. CENTRALIZED AUTHORITY In introducing the next speaker, Eastman noted that he had just con- ducted a survey of the American College of Surgeons Committee on Trauma (ACS-COT) state chairs. The survey asked whether, from the chair’s point of view, the state had a trauma system in place. The finding was that 54 per- cent of the chairs believed they had something resembling a trauma system. However, the survey showed that 100 percent of the state chairs believed they had a funding problem. The next speaker was John Fildes, national chair of ACS-COT. Fildes said that the trauma system is the “oldest, best-studied, and best-validated example of a regionalized emergency care system.” He added that the sys- tem is designed to ensure that if a person suffers a life-threatening injury or other emergency anywhere on the map of the United States, they will quickly move through a system of care that provides them with standardized and optimal care services. He said the Committee on Trauma came into being in the 1920s and began writing quality standards for ambulances. It was writing standards for in-hospital care even before the EMS movement of the 1960s and 1970s, he said. The professional organizations were seen as content experts, and the College of Surgeons embraced the notion that they could write standards for trauma.

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 REGIONALIZING EMERGENCY CARE COT established an ambulance inventory list and created courses on topics such as advanced trauma life support and prehospital advanced trauma life support. It also examined the question: “What equipment does a hospital need to have besides oxygen and electricity to treat patients?” COT also addressed the issue of how care should be standardized to ensure good outcomes, and developed trauma registries and performance improve- ment strategies. Fildes said the organization has experimented and learned how to set up effective systems, and now is able to offer trauma system consultations. Fildes expressed concern that as we go forward and begin to expand the regionalization model to other time-sensitive illnesses and injuries, if there is not a governmental authority to provide leadership, the result will be chaos. The effort will be driven by the profit motive and the institutions that are able to cobble together a sustainable business model, rather than by the best evidence and the best medicine. In the United States, Fildes said, 45 percent of states do not even identify themselves as having a system of care. There is no interoperability across boundary lines, and there is very little standardization. He said “the Com- mittee on Trauma is able to say what materials, personnel, processes, and guarantees need to be in place to deliver quality regionalized care. But as a professional organization, it is not an authority, so when a state comes to COT with a problem, COT has no authority to act.” Fildes concluded that “without this type of authority, regionalization is going to be very hard to put in place correctly. More likely,” he said, “it will become a free-for-all.” TRAUMA SYSTEM LESSONS Ellen MacKenzie, chair of the Department of Health Policy and Man- agement at the Johns Hopkins Bloomberg School of Public Health, said she had five takeaway messages to offer. First, we have very good evidence that trauma centers make a difference. They reduce the risk of dying and, for certain types of injuries, they can impact functional outcomes. More recent information shows that, although trauma center care is expensive, when you look at the cost compared to effectiveness, treatment at trauma centers are indeed cost-effective compared to other interventions. Second, if you compare where we are today against where we were in the 1970s, it is clear we have made incredible progress. This is easy to forget because there is still so much to be done, she said. But nearly every state now has the legal authority to designate trauma centers. Also, the percent of the population living within 45 minutes to an hour of a trauma center nationwide is 70-80 percent, which is very good. However, this level of access differs quite dramatically across the United States, and few states have implemented trauma centers based on population needs, which is critical.

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 REGIONALIZED TRAUMA CARE MacKenzie said we still need to define what regionalization is and what the characteristics of good regionalization are. We don’t know which trauma system models work better than others. She said we need to determine what the optimal number of trauma centers is and what their optimal configura- tion is, not just in terms of access but also in terms of volume, because the evidence is fairly strong that higher volume correlates with better outcomes. Therefore, increasing the number of trauma centers to increase access runs the risk of reducing volume at the verified or designated trauma centers and worsening outcomes. So these concerns should be balanced. Third, MacKenzie reiterated the point that, with respect to care delivery, “Regionalization is not centralization.” She observed that when trauma sys- tem development began, there was so much focus on ensuring that the most critically injured got to Level I/Level II facilities that we lost sight of the fact that the trauma system needs to meet the needs of all trauma patients, from the very minimally injured to the most critically injured. She said we have to design systems that meet the needs of all trauma patients, and not run the risk of pushing all the trauma cases into a limited number of facilities. Fourth, she said, designation of trauma centers as Level I, Level II, etc., is essential, but it is not enough. There also needs to be a coordinated EMS and referral system to direct patients to those facilities. This means devel- oping the trauma system, not just the trauma centers per se. Also, she said, there is a big difference between the percentage of people who have access to trauma care (i.e., the percent who live within a certain distance or time factor from a trauma center), and how many people actually get to trauma centers. Those figures can be quite different across the states. Finally, “we need to do a better job of accountability,” MacKenzie said. “We need to develop systems and then we must hold those systems account- able for performance. In order to do that, we need good metrics. . . . We’ve done a good job of designating trauma centers. We’ve done a great job in developing standards for trauma center care. But we haven’t done as good a job of developing metrics to evaluate the performance of trauma systems. Better metrics can also help the public in understanding the systems that are out there and what is missing. This can aid us in advocating for greater trauma system development across the United States.” AUDIENCE DISCUSSION Following the brief opening presentations, members of the audience participated in the discussion. Michael Handrigan, acting director of the Emergency Care Coordination Center, said that Boyd’s initial comment that regionalization is a verb may be grammatically incorrect, but it is right on point. Handrigan said regionalization is not about centralization and it’s not about designating certain facilities as the place to go for anything. It’s about

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6 REGIONALIZING EMERGENCY CARE how to structure the utilization of resources in any one location, given that one area will be very different from the next. The aim, he said, is to get the right resources to the right patient at the right time, which may not even involve moving the patient. It can also mean moving resources, personnel, or simply knowledge. Fildes agreed that regionalization is a verb, and said it’s one that involves utilizing resources and creating a hierarchical system that pulls together all elements as they exist in a community in order to optimize what they can do. Noting that the 2006 IOM committee envisioned an emergency care system that is regionalized, coordinated, and accountable, he said that coordination must be established by someone, otherwise market forces will drive it. Finally, he observed, accountability requires not just data and quality measures, but also an enforcement arm to make sure that people are doing what they’re supposed to be doing. The professional organizations have fallen short on that, and they are probably are not appropriate for that particular duty, he said. Richard Hunt of the Centers for Disease Control and Prevention (CDC) posed a fundamental question: “What is a region?” He said that the answer will dictate who receives funding and a greater allocation of resources. Is the region a jurisdictional boundary? A state? A county? Another type of geographical region? A trauma system with its Level I trauma center as the base for its catchment area? Hunt observed that there are probably many different answers to that question, but the issue is centrally important and we should spend time discussing it (see also Chapter 5). Eastman added that in the same vein we want to better define the term regionalization (see Chapter 2 for further discussion). Based on his experience in the 1970s, Boyd answered that there are 303 regions and at least 3 different types, as he described earlier. “They’re geographically contiguous . . . nobody’s outside a region.” They receive public monies and accept public responsibilities. “They are configured by the states. They were negotiated by the states. They weren’t strong-armed by me [the federal government].” Federal Lead Agency Jeffrey Upperman, director of trauma at Children’s Hospital in Los Angeles, asked Fildes to specify who should have the authority to oversee regionalization, as he mentioned in his presentation. Upperman discussed the biology of systems and asked, “Who should manage that biology going forward, as needs fluctuate and populations change over time?” Boyd asserted that “if no one is in charge, then the fools are at play.” He also noted that just having standards does not discipline the system. For example, you can have trauma centers that are trauma centers at 2:00 in

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 REGIONALIZED TRAUMA CARE the afternoon but not at 2:00 in the morning. “You have to have discipline in the system,” he said. This discipline comes from a lead agency, Boyd said, and from the person who can assume the role of a czar. This will be someone who is con- cerned about the system as a whole and is actually empowered to address problems. Boyd said that in some cases he was able to impose discipline on the sys- tem simply by bringing certain situations to public awareness. In those cases he didn’t have to regulate, or even criticize. For example, when hospitals’ capacity was unavailable at certain inconvenient hours of the day, this would simply be brought to the public’s attention. Somebody has to be in charge, Boyd said, and their authority has to come from an authoritarian base. This is the role of the lead agency. Then you have to fill the leadership position, and he believes this person has to be a physician. He said that emergency physicians have now assumed this role very nicely in many places. He emphasized that the person has to be a critical thinker and has to be willing to make tough calls. Fildes added that we need to look forward and think about the big-tent goal, which relates to emergency care overall. The big tent includes trauma, children’s issues, disaster issues, women’s issues, injury, time-sensitive illness—all sorts of things are included under the umbrella of emergency care, he said. There needs to be a top-down hierarchical approach to this with standardization at the state level and driven down into communities to make sure that emergency care functions across the entire continuum of prehospital and hospital care. He said the Emergency Care Coordination Center may be the group to take on that function. Eastman pointed out that the military’s trauma system may be instruc- tive because “obviously, it is built around hierarchy and authoritarianism.” He said “the best trauma system I have ever seen is the U.S. joint theater trauma system.” Governance of Regional Capacity Stephen Epstein, emergency physician at Beth Israel Medical Center in Boston, and previous chair of the American College of Emergency Physi- cians’ National Report Card Task Force, argued that regionalization is, to some degree, an issue of distribution of hospital and medical capacity. He asked whether distribution is best done at the state level, where trauma systems are governed, or at some other level? MacKenzie agreed that to some extent it is a distribution issue, but she said it’s not just about distribution of trauma centers, it’s also about structuring the utilization of EMS resources, communication capabilities, and so on. With respect to governance, she said, it depends on the state.

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 REGIONALIZING EMERGENCY CARE Larger states like California might prefer more regional governance, while smaller states like Vermont might prefer to maintain authority at the state level. She noted that Maryland has a statewide system that has worked very effectively. She added that if there are regionalized systems within a state, those systems have to be coordinated and have effective communication. Kenneth W. Kizer, who was central in designing the standards for the California EMS system in the early 1980s, said he was continually reminded of how challenging the issue of governance is. He noted that a county like Los Angeles is larger than the state of Connecticut and has a population greater than that of Michigan. “This underscores the need to have a balance between state and other.” Governance is a difficult issue, he said, because it involves a great deal of politics and economics that go well beyond the medical model. Eastman noted that cross-border relationships are important in terms of patient transport decisions. He said, “Just because you’re in north-central Wyoming, that doesn’t mean that you go to the trauma centers in Wyoming. You may well go to Billings, Montana.” He cited the role of helicopter transport in remote locations. Boyd argued that, in terms of distribution of resources, “a Rand McNally state map is more important than epidemiologic data, because you can see where things are and what their relationship is to something else.” (However, MacKenzie later asserted that what is needed is “Rand McNally plus epidemiologic data.”) On the issue of governance, Boyd noted that Arkansas, for example, was a weak state at the time because they did not have physician leadership. “That was the issue,” Boyd said. “Wherever we had physician leadership—first it came from surgeons, then from emergency physicians—this lead agency concept came into play.” Boyd said that the successful states were ones that maintained the lead agency concept. Maryland, he said, is truly one of the strongest in the coun- try, and it offers transferable lessons. He also noted that Eastman “runs a very strong and tight county-plus regional system” in San Diego. Boyd continued: in these cases, what do you have? “You have some authority that is recognized by the public as being responsible for this com- plex, multiplistic, changing thing called emergency care. Somebody is in charge.” However, he said deciding who that person is, or what that agency will be, is a challenge. He suggested: “this is where democracy has to work. You have to select somebody who represents the health interests of your community, and he or she (or it) is given the authority to manage this.” Determining Adequate Capacity Rick Niska, an emergency physician with the CDC’s National Center for Health Statistics, raised the issue of redundant capacity in the case of

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 REGIONALIZED TRAUMA CARE disasters. He asked, “Is that too much of a luxury to expect while region- alization is in its infancy, or should redundancy be part of the planning for regionalization from the get-go?” Eastman noted that over-designating or having too many trauma centers dilutes the higher volumes that are needed to improve performance and outcomes. “That’s really the dilemma that you have, [and] this issue is brought up every single time. How many Level I centers do we need? Do we know the equation?” Boyd argued, “You’ve got to have one in Peoria, [and] you’ve got to have one in Springfield. The trick is to have one in each of those towns and not two. That’s a political battle.” He added that “in Chicago you need 9, you don’t need 18.” He charged that “part of that second 9 are pretenders anyhow. They are the 3:00 p.m. trauma centers, but not 3:00 a.m. trauma centers.” How do you weed these out, he asked? “They all met the stan- dards. They all put in the application and they all got blessed by the Health Department.” The answer, he said, is through the czar, who is the only one who can bring credibility to the process. “The czar has to be backed by the College of Surgeons and ACEP and everyone else. He has some authority and he has [a] methodology.” Boyd maintained that “the problem with standards alone is that almost anyone can meet them. I have seen more dishonest hospital-categorization schemes than anybody in this world. And when you call them on it, there’s always some way out.” You must enforce accountability right from the start, he said. MacKenzie reinforced the point that “if you build in too much redun- dancy, then you’re going to dilute volume. We know that volume and out- come are very closely linked. That would be my real concern.” John Holcomb responded that, “you can function on a day-to-day basis pretty well with that model, [but] every 18 months or 24 months there’s a disaster that completely overwhelms the system and quality plummets because you’re completely overwhelmed.” He continued, “in a regionalized system, you must handle your day-to-day flow and you must have surge capacity for mass casualty. . . . It really is a balance.” Regionalization not Centralization Richard Wild, an emergency medicine physician and a regional chief medical officer for the Centers for Medicare & Medicaid Services (CMS) said he was struck by the earlier statement that regionalization is not centralization. “We should make that a mantra,” he stated. He regards this as a critical issue because, when talking about regionalized care, it is very easy to think only about Level I centers and forget about everything downstream.

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0 REGIONALIZING EMERGENCY CARE Wild said that, in overseeing the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), CMS often receives complaints that involve disagreements between Level I trauma centers and other non-Level I hospitals that may have the capability and capacity to handle cases such as minor penetrating trauma (e.g., stab wounds to the belly), but maintain that they must be seen at a trauma center. EMTALA was passed in 1986 to prevent hospitals from refusing to serve uninsured patients and “dump- ing” them on other hospitals. EMTALA imposed a mandate on hospitals, as well as physicians who provide emergency and trauma care, to provide a medical screening exam to all patients and to stabilize them or transfer them to an appropriate facility if an emergency medical condition exists. Wild argued that second- and third-order protocols are crucial in driving a regional system, because otherwise utilization will be “top-heavy,” i.e., skewed toward the Level I providers. MacKenzie said she agreed completely. From a research perspective, she said, there is still not a lot of good evidence regarding what the models of referral and coordination should be, and more needs to be done in that area. But, she added, systems should be based on need, whereas historically they have developed on more of an ad hoc basis. Eastman said he had recently been involved in a state trauma system consultation. The state “had defined an inclusive trauma system as: every- body who wants to be a trauma center, raise your hand.” He said the site team’s recommendation to the state was not that they needed a certain number of trauma centers. Rather, it was that they should conduct a needs assessment study and base the decision on the population base and the available evidence, as MacKenzie has suggested. Fildes added that as you move forward in establishing a regional system, there has to be a means of identifying and directing people in a way that is tiered and hierarchical. Building Inclusive Systems Eastman noted that the respondents to the ACS-COT survey are threat- ened by the politics of regionalization versus centralization, which often involves a battle between the haves and the have-nots. Boyd said we have to make sure the Level IIs and IIIs are still part of the system. A lot of the trauma centers, he said, have decided they want to be better than their neigh- bors and they want to gain a lot of resources. “But they have lost what I thought was really their real responsibility . . . that they are the supervisors, they are the guiders for their region . . . and they are the big brother of the smaller hospitals.” He continued, “That has to come back. I think it has to come back for clinical reasons, political reasons, and public health reasons.” He concluded that “a lot of the mystique around centralization” will need to fall away.

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 REGIONALIZED TRAUMA CARE Holcomb agreed, saying “you can have two different kinds of systems, and one is where you have a Level I trauma center and everybody goes there. That doesn’t work.” He said that model means training no longer happens at the outside hospitals, and so the personnel taking care of trauma patients at those facilities “are no longer capable, whether they are attend- ings, nurses, or residents.” Holcomb noted that in Houston during Hurricane Ike, one of the three Level I trauma centers shut down, leaving two Level I centers to serve a city of 5-6 million. Admissions at his facility increased dramatically. “We had a meeting shortly afterwards, and we said, ‘Look, we must have the Level IIIs step up; we must have them.’” He said that they did step up and it has resulted in positive changes. By changing the prehospital triage criteria and by getting the Level IIIs to do more, diversion rates at the Level I trauma centers are now down. He said this illustrates that a regional system of care must have hierarchical levels of care that function on a 24/7 basis. Eastman said that he had an opportunity to visit India and meet with a surgeon who had been at the hospital that received all of the casualties from the Mumbai massacre. Eastman said, “In Mumbai they did it all wrong.” All the patients were essentially taken to one hospital, and there were 25 other hospitals right there . . . who had surgeons, emergency physicians, nurses, blood, and they didn’t get it.” Brendan Carr, an emergency physician from the University of Pennsylva- nia, observed that “people here today have talked about inclusive systems, but many times when we talk about getting the [Level] IIIs into the game, we’re getting the [Level] IVs into the game.” He observed that “panelists have said we know what resources we have for emergency care, but then immediately went back to describing [what] we do know about Level Is and IIs.” He pointed out that “a third of all injured patients and a quarter of all severely injured patients show up in a non-trauma center. So they show up at a place where we don’t know anything about who’s staffing it, what resources are available, or what subspecialties are available.” Boyd responded that “we have forgotten about the Level III and the Level IV trauma centers. We have forgotten about how to relate to them and bring them into the system, and I think that’s what we have to do.” Instituting “Air Traffic Control” Andrew Bern, liaison to the American College of Emergency Physicians’ Task Force on Regionalization, said that if regionalization means getting the right resources to the right patient at the right time, it requires know- ing what those resources are and where they are. Right now we do not have that information. He recommended a national mandate establishing an ongoing, dynamic, real time needs assessment mechanism that provides

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 REGIONALIZING EMERGENCY CARE answers about what is going on. This would provide information on hospi- tal resources as well as all other emergency care resources. MacKenzie said we know a fair amount about what resources we have—certainly with respect to trauma centers and where they all are. But she said that we do not have a good handle on how those resources are being used, and we have to do a better job of understanding that. Fildes said we pretty much know where each of the emergency depart- ments is, each of the hospitals, each of the helicopter pads, each of the trauma centers, each of the children’s hospitals. We pretty much know where they’re physically located. The problem, he said, is that “there’s no air traffic controller in the tower.” MacKenzie agreed. Robert Neches of the University of Southern California said that there is a military concept called real-time situational readiness, which is supported by information technology. He said that this concept could be applied to track the status of patients and the medical forces responding. It is at least theoretically possible, he said, to know the moment-by-moment readiness of each medical facility to treat a patient or accommodate a patient surge. Eastman said that in San Diego we know the status of every trauma center in the city: how many beds they have, whether or not they are on diversion, how many ICU beds they have available, and so on. But he said it’s a baby step toward addressing multiple-casualty disaster scenarios. Fildes said “it is sad to acknowledge that Holiday Inn has a better idea of how many beds they have available than the U.S. hospital system [does].” As we move forward, he said, it will be essential to know which facilities have the capacity to treat a given patient at any given moment in time. He said that information technology has to be one of the underpinnings of a regionalized system, where a key consideration is how patients transition among and between resources. Neches underscored that it is possible to know not just how many beds are available, but how many ambulances are heading towards that facility. Greg Mears, medical director of North Carolina’s Office of EMS, said that there are now many satellite hospitals and freestanding emergency departments. Patients with a multi-system trauma may be treated at a trauma center but then be transferred to an outside specialty center for orthopedics, for example. He asked, in this regionalization approach, how do we deal with these “splinterized” hospitals where resources are scattered across campuses and are functioning in multiple regions? Fildes responded, “It comes down to again who’s in charge. We could promulgate a standard that says those transfers are not optimal, but there’s no effector arm, no disciplinary arm, because there’s no air traffic controller in the tower.” Holcomb noted that his Level I trauma center recently accepted a lip laceration case from an outlying hospital. He said there are at least two

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 REGIONALIZED TRAUMA CARE reasons why a transfer like this might occur: “one, the doctor doesn’t feel comfortable, or two, the facility is not capable. Either way, they determine the patient is better handled elsewhere.” Holcomb argued this is why lower level facilities should be required to maintain a 24/7 level of care and this should be a defining element of regionalization. Also, redirecting less serious cases to lower-level centers could help free up subspecialists during peak times. Neurosurgeon Alex Valadka noted that “most neurosurgical centers get overwhelmed by cases that probably don’t need to be there, but could be safely managed at a Level III or a Level IV facility.” Implications for Training and Residency David Sklar of the University of New Mexico and ACEP commented that, if we were to regionalize other care systems in the way that we have for trauma, there would be major implications for medical student training and residency. For example, residents might not get the experience they need for their training. He said that, in trauma systems, because of the way that Level I trauma centers were designated, residents for surgery, emergency medicine, and others continue to get the experience they need. However, that might not be the case with other kinds of illnesses. John Fildes responded that, as you move forward into a regionalized system, what you find is that the patient cannot be taken apart. In the case of a patient who has an epidural hematoma, a pneumothorax, a ruptured spleen and a femur, it’s not possible to send the patient’s brain to the neuro- surgery hospital and the femur to the orthopedic hospital and the spleen to the general surgery hospital. What happens is there will be an overlay where these specialties stack up. This will create ideal training environments for emergency medicine, surgery, and other specialties as well, he said. Fildes acknowledged that creating an inclusive trauma system that is not overly centralized in the hands of large facilities is essential because if every patient is sent to only one place, then all the other places would lose their abil- ity to perform those functions. This gets down to the issue of patient triage. Rather than moving all patients to one “megacenter,” patients should also be sent to other nodes where they can be treated perfectly well and where training can take place. Fildes said it is “very, very important to keep this anti-centralization theme out front and to make sure that there is an inclusive treatment system that allows adequate access of trainees for residencies.” Boyd said that something that is very helpful to regional development is to have training within regional systems. He said spending a week to train in critical care, in the emergency department, and in other parts of a hospital has a powerful binding effect on the regional system. This can be part of the glue that holds the system together, because it strengthens the team concept and aids regional development.

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 REGIONALIZING EMERGENCY CARE Bailey added that EMS is also part of the system and need to be included in training plans. He said it is the delivery mechanism to the trauma center in most instances. The training that takes place should also address the hospitals that patients should be directed to. Kizer added that the impact on training centers should not be under- estimated. Having been involved in trying to regionalize a number of different types of services, he observed that “the major opposition to this consistently comes from academic health centers or academic university training programs because of the impact it can have on [their] training programs.”