The elderly account for a disproportionate share of injury-related hospitalizations (see Chapter 2). Demographic projections suggest that their share of hospitalizations is likely to grow even more. The need for the full range of treatment efforts targeted to the elderly is especially critical, particularly the need for a seamless transition from prehospital to acute care to high-quality rehabilitation services tailored to their needs (IOM, 1997a). There is some evidence that the elderly with major trauma have an inferior quality of trauma care compared to other age groups. This problem may be the result of two factors: (1) inadequate triage criteria for dispatching an elderly patient to a trauma center, resulting in undertriage (Phillips et al., 1996; Ma, 1997), and (2) a higher risk of complications and death during hospitalization (DeMaria et al., 1987; Champion et al., 1989a; Finelli et al., 1989; Chen et al., 1995; Ma, 1997). More research is needed to identify causes, sequela, and interventions to ensure the highest quality of care for elderly patients.

System Management and State or Regional Agencies

It has long been recognized that trauma care systems are best managed on a regional basis by virtue of the opportunity to pool and centralize resources and the relative infrequency of major trauma (NRC, 1978; Eastman et al., 1987; Stewart et al., 1995). Major trauma generally accounts for a small percentage (10–12 percent) of overall injury admissions (MacKenzie et al., 1990; National Trauma Data Project, 1996). Injury admissions—of all types and levels of severity—ranged in 1993 from 6.19 to 9.02 admissions per thousand population (National Trauma Data Project, 1996). Consequently, state and regional agencies have come to play essential roles in establishing and coordinating regional and local trauma care systems, many of which receive assistance from the federal government.

Federal legislation since the 1970s, such as the Emergency Medical Services Systems Act of 1973 and the Trauma Care Systems Planning and Development Act of 1990, channeled funds to states and regions in order to cultivate the development of systems of care (Table 6.1 contains a chronology of federal trauma system legislation). The 1990 legislation not only authorized funding for development and planning activities (albeit unsustained funding; see later section on financing trauma systems), but also stipulated the creation of a Model Trauma Care System Plan (HRSA, 1992).



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