Historical Development of Hospital-Based Emergency and Trauma Care
HOSPITAL-BASED EMERGENCY CARE
The modern emergency department (ED) developed at a time when the specialization of medical practice swept the nation after World War II, and it reflects the general trend toward hospitals as a site of medical care rather than homes and physicians’ offices. As the practice of generalist physicians making house calls declined, patients increasingly turned to the local hospital for treatment. This trend was reinforced by the development of private insurance plans, which geared payments toward hospitals and away from home visits (Rosen, 1995). The development of the ED also reflects the passage of the Hill-Burton Act of 1946, which gave states federal grants to build hospitals provided that the states met a variety of conditions, including a community service obligation. Among other things, the community service obligation requires hospitals receiving Hill-Burton funding to maintain an emergency room. This requirement applies to the vast majority of nonprofit U.S. hospitals in operation today (Rosenblatt et al., 2001).
But hospital-based emergency care was really spurred forward by developments in trauma care that resulted from America’s wartime experiences. World War II saw the development of blood transfusions, resuscitation, rapid transport of injured patients to field hospitals, and advances in surgical care of injuries. Military medicine advanced further during the Korean and Vietnam wars with the introduction of medical evacuation by helicopter to mobile field hospitals. Modern emergency medical services (EMS) and trauma systems grew out of a growing recognition that these methods could also be applied to civilian populations back home (Boyd, 1983).
Coincident with developments in the treatment of injuries were advanc-
es in the treatment of acute coronary syndrome (ACS). In Belfast, Ireland, Dr. Frank Pantridge was demonstrating that a mobile coronary care unit could substantially reduce mortality among heart attack victims (Pantridge and Geddes, 1967). Following his lead, several medical centers in the United States began programs to deliver rapid emergency care to cardiac patients. William Grace, for example, established a mobile coronary care unit at St. Vincent’s Hospital in New York City—the first of its kind in America—that transported physicians to the scene of patients experiencing ACS (Key et al., 2005). Other programs were started independently in Los Angeles, Seattle, Columbus, and Miami.
The recognition that injured or acutely ill people could be saved if they received treatment within a short span of time led to the development of prehospital EMS systems designed to get patients to the hospital quickly. This in turn stimulated the development of hospital-based emergency care and the specialty of emergency medicine. The introduction of new technologies that facilitated the rapid diagnosis and treatment of injuries and acute illnesses, such as the computed tomography (CT) scan and cardiac monitoring, contributed to this growth.
Public interest in the importance of emergency services was sparked by the 1966 landmark National Academy of Sciences/National Research Council (NAS/NRC) report Accidental Death and Disability: The Neglected Disease of Modern Society (NAS and NRC, 1966). The report described the epidemic of automobile and other injuries—due in part to the expansion of the interstate highway system—and the deplorable system for treating these injuries nationwide. At the time, most emergency rooms appeared to offer only advanced first aid; only a few facilities had the staff and equipment to provide complete care for seriously ill or injured patients. Patients who appeared at the hospital were often turned away if they did not have funds to pay for their care, and transfers to the city or county indigent care facility were conducted without concern for patients’ well-being (Rosen, 1995). To many in the field, the 1966 NAS/NRC report marked the beginning of the modern emergency care system. Coupled with advances in military medicine and civilian cardiac care, this report led to the Highway Safety Act of 1966 (P.L. 89-564), which created the National Highway Traffic Safety Administration (NHTSA) within the Department of Transportation and required states to develop regional emergency care systems.
The growing demand for emergency care and the difficulty of finding physicians to provide it led hospitals to require that active medical staff take turns covering the ED at night and to hire additional ED staff, regardless of their skills or experience. Eventually, some physicians gave up their regular practices to work in the ED full time. One of the first to do so was James Mills, M.D., who started the Alexandria Plan in 1961, a group made up of physicians who worked only in the ED. Similar plans in Pontiac and Flint,
Michigan, soon followed. Because of the advantages to hospitals of having a steady, full-time team covering the ED, hospitals began contracting for emergency services, and an increasing number of physicians decided to work in EDs full time. Most private physicians entering this new field had no specialized medical training; they entered ED practice after completing only an internship (Rosen, 1995).
The Emergency Medical Services Systems Act of 1973 (P.L. 93-154) created a new grant program in the Division of EMS in the Department of Health, Education, and Welfare (DHEW) to foster the development of regional EMS systems. NHTSA simultaneously funded the prehospital components of EMS systems and oversaw the development of curricula and training for EMS professionals. A number of advances resulted from this confluence of efforts, including the establishment of state coordinating offices and local EMS planning councils, the proliferation of trained emergency medical technicians (EMTs), and the development of air transport services.
But while EMS systems benefited from an influx of federal funding in the 1970s, EDs received less support, and deficiencies remained. Throughout the 1970s, a pattern was established of soaring ED patient volumes along with relative neglect of the needs of EDs.
In the early 1980s, the period of strong federal leadership and funding for the development of emergency care came to an end with the passage of the Omnibus Reconciliation Act of 1981 (P.L. 97-35). This legislation replaced the categorical funding for EMS activities in the states with Preventive Health and Health Services Block Grants that allowed states to allocate federal EMS dollars to other programs. The act eliminated most emergent care activities under DHEW, and spending on EMS dropped dramatically. NHTSA therefore became the de facto federal lead agency for emergency care activities, although its emphasis was even more focused on prehospital activities than DHEW’s, and even NHTSA’s funding for EMS, provided through Section 402 of the State and Community Highway Safety Program, was reduced (IOM, 1993). A General Accounting Office (GAO) report found that funding fell by 34 percent between 1981 and 1983. Funding also shifted to the states: in 1981 about 27 percent of funding was from state and local funds; by 1988, the state and local share had increased to 82 percent (GAO, 1986).
Also in the 1980s, the importance of prevention of injury was becoming more widely recognized and was highlighted in the 1985 NAS/NRC report Injury in America: A Continuing Health Problem (NRC and IOM, 1985). This report led to the establishment of the Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control in 1992. Also, a growing recognition of the unmet emergency care needs of children, particularly among professional organizations such as the Ameri-
can Academy of Pediatrics, the American College of Emergency Physicians (ACEP), the Society of Critical Care Medicine, and the National Association of EMS Physicians, led to the establishment of the Emergency Medical Services for Children (EMS-C) program within the Department of Health and Human Services (DHHS) as part of the Health Services, Preventive Health Services, and Home and Community Based Services Act of 1984 (P.L. 98-555). The EMS-C program, established as a demonstration grant program despite its longevity, has funded two resource centers and established grants to states for the development and implementation of EMS-C programs. While focused on pediatrics, the program has worked closely and jointly funded general projects with NHTSA and other federal partners to promote both general enhancements that will benefit children and the integration of children’s issues into general emergency care planning and activities.
THE DEVELOPMENT OF TRAUMA CARE
Trauma represents a particular kind of medical emergency. It is typically defined as involving a physical wound caused by force or impact, such as a fall, automobile crash, or gunshot; burns and other severe wounds are also considered a form of trauma. Life-threatening emergencies caused by preexisting conditions, such as a heart attack, are generally not considered trauma. Trauma care is distinguished from care received in a general ED by the severity of the injury and the specialized diagnostic and treatment procedures necessary to care for the patient. Ideally, traumatically injured patients are cared for in a trauma center, a hospital that is able to receive such patients 24 hours a day, 7 days a week. Trauma centers are designed to meet the complex surgical needs of critically injured patients immediately. To qualify as a trauma center, a hospital must have a number of capabilities, including a resource-intensive ED, a high-quality intensive care ward, and an operating room that is functional at all times.
The development of trauma care mirrors the development of surgery in general and has been stimulated by wartime experiences. The seeds of the modern trauma system can be traced to the beginnings of the American College of Surgeons (ACS), which was founded in 1922 (Trunkey, 2000). The ACS established a Committee on Fractures, as well as the Hospital Standardization Program, which collected data on fracture injuries, thus becoming the first trauma registry. (This program later became the Joint Commission on Accreditation of Healthcare Organizations [JCAHO].) The ACS later formed the Board of Industrial Medicine and Traumatic Injury in 1926.
Rapid advances in medical treatment and in the rapid delivery of patients to hospitals occurred during World Wars I and II and the Korean and Vietnam wars, and the current conflict in Iraq continues this pattern, with
a number of important advances being made. The modern era of trauma care is equally concerned with the development of trauma care systems. San Francisco General Hospital and Cook County Hospital in Chicago began the development of systematic approaches to trauma care. These efforts were closely followed by the development of Maryland’s statewide trauma care system by R. Adams Crowley (Trunkey, 2000). In 1976, the American College of Surgeons Committee on Trauma (ACS COT) published formal criteria for trauma systems—Optimal Criteria for the Care of the Injured Patient—which included the categorization of trauma centers based on their capabilities in treating traumatic injuries (ACS COT, 1999).
Optimal Criteria for Care of the Injured Patient
The development of trauma systems, which was limited to a few states before 1990, accelerated greatly with the enactment of the Trauma Care Systems Planning and Development Act (P.L. 101-590) in 1990, and the number of trauma centers nationwide began to increase rapidly. This program was eliminated in 1995, leaving a gap in federal leadership on trauma system development until the creation of the Trauma/EMS Systems Program within the Healthcare Resources and Services Administration’s (HRSA) Division of Healthcare Preparedness in 2001. This new program again provided national leadership for trauma care planning, infrastructure development, standards development, and coordination with other federal agencies until it, too, was zeroed out of the federal budget for fiscal year 2006.
A trauma system is a coordinated approach to trauma care and injury prevention. It is based on the premise that optimal care is delivered to injured patients when preconceived processes and resources are coordinated in an organizational plan. A well-organized trauma system allows patients to move seamlessly and expediently through the system. The formality of trauma systems varies by states. Almost all systems have standardized triage processes and constant oversight over trauma centers, but systems vary on many other factors, including designation processes and criteria for interfacility transfers.
The most recent nationwide inventory of trauma centers was published in 2003, based on data collected in 2001–2002. A total of 1,154 trauma centers were identified in the 50 states and the District of Columbia; an additional 31 trauma centers treat only children. Every state has at least one trauma center of some level, and all but Arkansas have at least one level I or level II (the most sophisticated).
An important aspect of trauma systems is the categorization of hospitals according to the level of trauma services they provide. This information is then used by regional EMS agencies and community hospitals to direct trauma patients to the most appropriate level of care given their condition
and location. The process of categorizing hospitals was pioneered in 1976 by ACS COT, which today is the principal body for verifying that trauma centers meet accepted standards of trauma care. The Verification Review Committee, a subcommittee of ACS COT, was established in the late 1980s to conduct on-site consultations and verifications. Consultations are conducted at the request of a hospital, community, or state authority to prepare a facility for a verification review. Verification review is ACS COT’s process of assessing the trauma care capabilities of a facility based on the criteria contained in Resources for Optimal Care of the Injured Patient. Through the verification review process, a facility is established as a level I, II, III, or IV trauma center based on a variety of factors, including the volume of severely injured patients, 24-hour availability of trauma surgeons and other specialists, whether these specialists are in house or on call, the surgical capabilities of the center, and the availability of specialized equipment. (See Box F-1.)
Designation is the process by which local governments designate specific facilities as trauma centers within their system, usually based on ACS COT verification. A minority of trauma centers are verified not by the ACS COT process, but by a state verification process. The criteria and categorization systems used by states that conduct verification can vary, and some states include a fifth level of triage designation. Level V trauma centers are not formally recognized by the ACS, but they are used by some states to further categorize hospitals providing life support prior to transfer.
Current Issues in Trauma Systems
Although trauma centers and trauma systems have developed extensively over the last two decades, a number of critical issues remain.
Lack of Regional Coordination
Ensuring that each patient is directed to the most appropriate setting for care requires that many elements within the regional system—community hospital, trauma centers, and particularly prehospital EMS—effectively coordinate the regional flow of patients. In addition to improving patient care, coordinating the regional flow of patients is a critical tool in reducing overcrowding in EDs. Few systems nationwide have effective coordination between EMS and hospital EDs and trauma centers and actively direct patients to the best location based on current availability of beds, operating rooms, specialists, and critical equipment.
Classification System for Trauma Center Levels of the American College of Surgeons Committee on Trauma
Provides comprehensive trauma care; serves as a regional resource; and provides leadership in education, research, and system planning. A level I center is required to have trauma surgeons, anesthesiologists, physician specialists, nurses, and resuscitation equipment immediately available. Volume performance criteria further stipulate that level I centers must treat 1,200 admissions per year or 240 major trauma patients per year or an average of 35 major trauma patients per surgeon.
Provides comprehensive trauma care either as a supplement to a level I trauma center in a large urban area or as the lead hospital in a less population-dense area. Level II centers must meet essentially the same criteria as level I, but volume performance standards are not required and may depend on the geographic area served. Centers are not expected to provide leadership in teaching and research.
Provides prompt assessment, resuscitation, emergency surgery, and stabilization, with transfer to a level I or II center as indicated. Level III facilities typically serve communities that lack immediate access to a level I or II center.
Provides advanced trauma life support prior to patient transfer in remote areas in which no higher level of care is available. The key role of a level IV center is to resuscitate and stabilize patients and arrange for their transfer to the closest and most appropriate level of facility.
Decreased Pool of Trauma Surgeons and Other Specialists
There is a declining pool of trauma surgeons and on-call specialists because of the large amount of uncompensated care they are required to provide, the extraordinary medical malpractice risk involved, and the lifestyle burdens associated with providing emergency call day and night.
Loss of Trauma Centers
Trauma care is expensive to provide and often is poorly compensated. As a result, level I trauma centers have been closing in major cities because of the financial pressure of caring for uninsured and underinsured patients. When a trauma center closes, nearby centers are under substantial pressure to take additional patients. The loss of regional trauma capacity can be perilous for patients, as it can increase the time required to reach definitive care.
MILITARY EMERGENCY AND TRAUMA CARE
Just as the U.S. civilian emergency care system benefited from advances made in military medicine during the Vietnam and Korean wars, the civilian system may benefit from further medical advances being made during the current U.S. military operations in Afghanistan and Iraq. Indeed, military medics and physicians today have better information and tools at their disposal relative to those involved in previous military engagements, and these advances are expected to reduce battlefield deaths considerably. The Iraq war has produced the lowest casualty fatality rate ever seen in combat among injured U.S. soldiers (Connolly, 2004). In many respects, military medicine is well ahead of the civilian trauma system in place today.
One important advance has been the development and implementation of a medical information management system for military forces. In past military engagements, soldiers carried paper medical cards to be inserted into their medical records at a later time. However, the cards would often get damaged or lost, leaving field medics with little information on wounded soldiers (Campbell, 2005). In 1999, the Department of Defense adopted Medical Communications for Combat Casualty Care (MC4), a system that contains digitally secure, accurate medical histories of soldiers and makes that information available to military clinicians around the world. The system incorporates information from pre- and postdeployment health surveys, and military medics enter additional information from the field using MC4 laptops and handheld devices if a soldier is wounded (Onley, 2003; Steen, 2005). Medics can also use the system to order supplies, find information on drug doses and physician references, and track the movement of patients as they receive higher levels of care (Onley, 2003). The central database allows medical specialists to track trends and conduct surveillance, with the hope of eliminating the phenomenon that occurred after the Gulf War, when soldiers came back with unusual symptoms, and there was no paper trail documenting what chemicals they were exposed to or what care they may have received. Although a number of brigades in Iraq are still using paper records, more than 10,000 deployable medical and ancillary professionals
have been trained on the MC4, and the system is being used by more than 250 units in Iraq (Onley, 2003; Steen, 2006).
The military has also improved access to medical care so that wounded soldiers receive higher levels of care more quickly. To this end, the military has moved its medical assets closer to the front lines and improved air medical capabilities (Miles, 2005). The Marine Corps and the Navy introduced forward resuscitative surgery systems—small, mobile trauma surgical teams of eight individuals (two surgeons and support staff) designed to provide tactical surgical intervention for combat casualties in the forward area (Chambers et al., 2005). The units can erect a battlefield hospital with two operating tables and four ventilator-equipped beds in less than 1 hour (Gawande, 2004). New medical technologies, such as compact ultrasound and x-ray machines, generators that extract pure oxygen from the air, and computerized diagnostic equipment, have allowed the teams to provide fairly sophisticated care (Barnes et al., 2005). With these new surgical teams, however, the U.S. military’s strategy is to conduct damage control in the field—stop bleeding, keep a patient warm—and leave definitive care to physicians at a hospital. Surgeons limit surgery to 2 hours or less and send the patient off to the next level of care.
Air medical evacuation procedures and equipment have improved to allow rapid transport of a critically injured solider. Thanks to those advances, the Air Force is transporting patients that it would have never considered moving in previous wars (Miles, 2005). From the field surgery teams, patients are brought by helicopter to a larger combat support hospital in Iraq. Air medical evacuations are now lighter and more adaptable; patient support pallets can be moved from one aircraft to the next, and medical teams carry much of their equipment in backpacks. If a soldier is critically wounded, a critical care air transport team joins in the air medical evacuation to help transport the patient to a combat hospital in Iraq, which has additional equipment.
Patient stays at military hospitals in Iraq are brief. Patients are transported as quickly as possible on an aircraft to a U.S. hospital in Germany. Today, the military is able to transport patients on a larger variety of aircraft than in the past, so there is no need to wait for a specific plane to arrive. One aircraft, the C-17 Globemaster III, has the ability to move 70 patients at a time, including 9 with critical injuries. The plane is quieter, vibrates less, and has more temperature control than its predecessors. With medical information systems in place, air medical evacuation teams have detailed information about patients’ medical history, medications, medical conditions, and procedures already performed (Miles, 2005). Whereas it took an injured soldier in Vietnam 45 days to reach a U.S. facility, today soldiers go from the battlefield to a U.S. hospital in less than 4 days, and continuous medical care is provided throughout the journey (Gawande, 2004).
The training of medics has also advanced. In the past, medics learned from books and rarely practiced on live patients. Today, training is conducted using specially developed computer software that asks trainees to make critical-care decisions and then provides feedback on the impact of those decisions on the patient. The practice mannequins have mechanized lungs and vital signs controlled by computer (Online NewsHour, 2003).
Soldiers and medics also have new medical tools in Iraq. They carry a new tourniquet designed for one-handed application, so that a solider can apply the tourniquet to himself or herself if necessary (Crisp, 2005). Additionally, many soldiers and medics now carry bandages coated with blood clot–forming compounds that can stop life-threatening bleeding quickly. Anticlotting products are critical since profuse bleeding is a primary reason for casualties on the battlefield (Kolata, 2003). In the past, medics relied simply on gauze and tape (Mishra, 2003). Many special operations medics are carrying hetastarch instead of bulky bags of intravenous saline solution. Hetastarch is a more compact material, making it easier to carry, and it stays in the vascular system longer than saline, helping to maintain blood pressure (Barnes et al., 2005).
The armed forces continue to investigate new ways to improve survival rates in combat zones. As an example, the U.S. Army and Navy commissioned an outside firm to form an expert panel to review and rank research proposals for resuscitation fluids and therapies to determine which held the most promise for improving survival. A second expert panel was convened to examine and improve the ways in which the military obtains results from scientific research for military medicine (Krupa, 2005). Air Force officials report working daily to improve air medical communications, equipment, and procedures (Miles, 2005).
ACS COT (American College of Surgeons Committee on Trauma). 1999. Resources for Optimal Care of the Injured Patient. Chicago: ACS.
Barnes J, Roane K, Szegedy-Maszak M. 2005, April 5. Stemming the fatalities with a modern touch. Sydney Morning Herald.
Boyd DR. 1983. The history of emergency medical services (EMS) systems in the United States of America. In: Boyd DR, Edlich RF, Micik SH, eds. Systems Approach to Emergency Medical Care. Norwalk, CT: Appleton-Century-Crofts.
Campbell P. 2005, December 12. APL helps Army choose systems for digitizing medical records. The Johns Hopkins University Gazette.
Chambers LW, Rhee P, Baker BC, Perciballi J, Cubano M, Compeggie M, Nace M, Bohman HR. 2005. Initial experience of U.S. Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom. Archives of Surgery 140(1):26–32.
Connolly C. 2004, December 9. U.S. combat fatality rate lowest ever. The Washington Post.
Crisp JD. 2005, July 18. New tourniquet issued to deployed soldiers. Defend America.
Gawande A. 2004. Casualties of war: Military care for the wounded from Iraq and Afghanistan. New England Journal of Medicine 351(24):2471–2475.
GAO (U.S. General Accounting Office). 1986. States Assume Leadership Role in Providing Emergency Medical Services (GAO/HRD-86-41). Washington, DC: GAO.
IOM (Institute of Medicine). 1993. Emergency Medical Services for Children. Washington, DC: National Academy Press.
Key CB, Lewis R, Schaal S. 2005. How today’s street medicine evolved form the Columbus Heartmobile & other pioneering projects. Journal of Emergency Medical Services 30(12):48–55.
Kolata G. 2003, March 30. Armed with new tools, doctors head to battle. The New York Times.
Krupa D. 2005. Armed Forces Search for Ways to Improve Survival in the Combat Zone (Press Release). Bethesda, MD: Life Sciences Research Office. [Online]. Available: http:// www.lsro.org/newsroom/resuscitation_press_release_2005_07_25.pdf [accessed May 20, 3006].
Miles D. 2005, August 10. Aeromedical evacuation improvements saving lives. DefenseLink News.
Mishra R. 2003, March 25. Advances in battlefield medicine pay off immediately. Boston Globe.
NAS, NRC (National Academy of Sciences, National Research Council). 1966. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences.
NRC, IOM (National Research Council, Institute of Medicine). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press.
Onley D. 2003. Medics tap patient data. Government Computer News 22(7).
Online NewsHour. 2003. Combat Medicine. A NewsHour with Jim Lehrer. [Online]. Available: http://www.pbs.org/newshour/bb/military/jan-june03/medicine_3-29.html [accessed May 20, 2006].
Pantridge JF, Geddes JS. 1967. A mobile intensive-care unit in the management of myocardial infarction. Lancet 2(7510):271–273.
Rosen P. 1995. History of Emergency Medicine. New York: Josiah Macy, Jr. Foundation. Pp. 59–79.
Rosenblatt R, Law S, Rosenbaum S. 2001. Law and the American Health Care System. New York: Foundation Press.
Steen R. 2005. A gateway to medical information for deployed. Military Medicine Technology 9(4).
Steen R. 2006. U.S. Embassy Clinic in Iraq Uses Digital Medical Recording System: Medical Communications for Combat Casualty Care Connects Clinic to Combat Support Hospital. [Online]. Available: http://www.dcmilitary.com/army/standard/12_26/national_ news/38937-1.html [accessed May 20, 2006].
Trunkey DD. 2000. History and development of trauma care in the United States. Clinical Orthopaedics & Related Research (374):36–46.