which until 1995 encouraged the development of, and provided funding for, inclusive systems (see later discussion of financing). The effectiveness of an inclusive system has yet to be empirically evaluated (NCIPC, 1993).

BOX 6.1 The Continuum of Care

Prehospital Emergency Medical Services (EMS) Prehospital care is the gateway to the trauma care system and a major determinant of patient outcome (Jacobs et al., 1984; Rutledge et al., 1993; Regel et al., 1997). The goals of prehospital care are prompt arrival at the scene, assessment of patients' needs through medically approved protocols for triage (the classification of injury severity and the selection of a hospital destination that matches patients with appropriate clinical resources); preliminary resuscitation and treatment; and rapid transport to the nearest, most appropriate acute care facility (ACS, 1993; Jacobs and Jacobs, 1993). Access to prehospital care is provided almost universally throughout the United States by a telephone call to 9-1-1 (NHTSA, 1997a). There are four levels of EMS providers: (1) first responder, (2) emergency medical technician (EMT)-Basic, (3) EMT-Intermediate, and (4) EMT-Paramedic. The paramedic has substantially more training than the others and is the provider of most advanced life support given outside the hospital.

Acute Care Hospitals and primary care providers diagnose and treat the majority of injured patients, but the cornerstone of the trauma care system is the trauma center. Trauma centers are highly sophisticated facilities geared to the most gravely injured. Four levels of trauma center, each with detailed qualifying criteria, have been established and revised by the American College of Surgeons (ACS, 1993). (See Box 6.2 for a description of Level I–IV trauma centers). Many states with the legal authority to designate trauma centers use the ACS's criteria for designation. Hospitals seeking designation in states where such formal authority is lacking often rely on verification by the ACS that they have met its criteria.

Rehabilitation Rehabilitation forms the final, and generally the longest, phase of treatment in a trauma care system. The goals of rehabilitation are to improve physical and mental health, reduce disability, and enhance personal autonomy and productivity. Rehabilitation is defined as the process by which physical, sensory, or mental capacities are restored or developed. It is a process that is accomplished through functional improvements in the patient, as well as through changes in the physical and social environment (IOM, 1997a). Rehabilitation is offered on an inpatient or outpatient basis in a designated hospital unit, a freestanding rehabilitation hospital, or in a clinic. In a model trauma care system, rehabilitation begins at the earliest stage possible after admission to an acute care hospital (HRSA, 1992; NCIPC, 1993).



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