Tra u m a S y s t e m s

Origins, Evolution, and Current

Challenges

Danielle A. Pigneri, MDa, Brian Beldowicz, MD

a,b
,
Gregory J. Jurkovich, MDc,*

KEYWORDS
 Trauma systems  Regionalized care  Governmental oversight
 Trauma as major cause of death

KEY POINTS
 Trauma is a major cause of death and major cause of life-years lost.
 Outcomes within trauma systems are markedly improved compared with areas without
trauma systems.
 The growth and development of trauma systems is reliant on governmental oversight,
financial support, and public interest.

Trauma is the leading cause of death in the United States for people younger than 45,
and more children die of injuries than all other causes combined. Trauma is the fifth
leading cause of death overall, and accounts for 25% of all life-years lost, more
than cancer and heart disease combined. More than 130,000 Americans die every
year in our communities from injury, and the combination of health care expenditure
and loss of productivity due to injury is estimated to be $675 billion per year.1 Trauma
systems are an effort to address a real and pressing need, and the trauma system
effectiveness is a key determinant of the health of a community. Not only does injury
happen at unpredictable moments, but the elapsed time from injury to definitive care
dramatically affects outcomes. For these reasons, a system that is organized, pre-
pared, and has dedicated providers is of paramount importance. The ideal trauma
system design is often referenced to a document published by the Health Services
Research Administration in 1992.2,3 Hallmarks of that report were the recognition
that a well-functioning trauma system must integrate all phases of care to allow for

a
Division of Trauma, Acute Care, and General Surgery, Department of Surgery, UC Davis
Health, 2315 Stockton Boulevard, Room OP 512, Sacramento, CA 95817, USA; b Division of
Trauma, Acute Care, and General Surgery, Department of Surgery, Uniformed Services Univer-
sity of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; c Division of
Trauma, Acute Care, and General Surgery, Department of Surgery, UC Davis Health, 2221 Stock-
ton Boulevard, Cypress #3111, Sacramento, CA 95817, USA
* Corresponding author.
E-mail address: [email protected]

Surg Clin N Am 97 (2017) 947–959

http://dx.doi.org/10.1016/j.suc.2017.06.011 surgical.theclinics.com
0039-6109/17/ª 2017 Elsevier Inc. All rights reserved.
948 Pigneri et al

smooth management of and transitions between recognition, stabilization, transport,

treatment, and rehabilitation of the injured. There must be appropriate availability of
specialists without overcrowding the system. A wide breadth of specialists should
be concentrated in the centers that deal with the most gravely injured patients, and
a network of lower severity hospitals should expediently transfer severely injured pa-
tients, once stabilized, to these centers. The location of these centers with various ca-
pabilities should be based on need, meaning it is to some extent an exclusionary
system. Standards of care must be defined, adhered to, and constantly reexamined
for opportunities for improvement. Injury prevention outreach should be instituted to
decrease the total burden of injury within a community. The ideal trauma system would
enable data sharing to effectively analyze care, identify shortcomings, and provide a
mechanism for continued improvement in quality.
Although organized civilian trauma systems and the designation of a trauma center
are fairly new, the concept of triaged trauma care is as old as war. Many of the lessons
learned regarding treatment of traumatic injury were first learned on the battlefield. The
Civil War is attributed with being the first time that resources, including anesthetics,
were organized to support the surgeon at the scene. The first and second World
Wars are credited with the first use of blood transfusions and the first recognition of
the effect of time to treatment on outcomes.4,5 With further scientific advancement
in pharmacology, antisepsis and surgical technique available in each successive
war of the nineteenth, twentieth, and now twenty-first century, the systematic applica-
tion of triage, evacuation, and resource allocation exerted as much influence on mor-
tality as the weapons of war themselves. A 1961 study of Army personnel highlighted
the prevalence of delayed diagnosis and inappropriate treatment in soldier deaths,
calling for improved organization of military medical care for the injured. The high con-
centration of complex injuries observed in war demanded time-sensitive transporta-
tion of injured soldiers to strategically distributed medical assets with specialized
capability. Inadequate supply or inefficient use of such assets could be detected by
a measurable, and preventable, loss of lives.
As advances were made on the battlefield, the value of applying these principles to
the care of injured civilians was recognized. The first formalized civilian trauma center
is commonly recognized as the Birmingham Accident Hospital and Rehabilitation Cen-
ter located in Birmingham, United Kingdom, which opened its doors to the injured in
1941. This hospital was the first to separate injured patients from medically ill patients
and structured treatment plans to include all phases of care, from initial resuscitation
to rehabilitation.6
The first organized civilian US committee dedicated to the care of the injured was
the Committee on Fractures, founded in 1922 and chaired by Charles L. Scudder.
This was later merged with the American College of Surgeons (ACS) Committee on In-
dustrial Medicine and Traumatic Surgery in 1939 to create the Committee on Fractures
and Other Trauma. Over time, the focus of this committee expanded to include
visceral injuries in addition to the continued attention to skeletal injuries. Reflecting
this change, in 1950 the committee was given its current name, the ACS Committee
on Trauma (COT).7 The ACS COT has defined national standards for the care of the
injured. The Optimal Hospital Resources for Care of the Seriously Injured was first
published by the ACS COT in 1976 and defined the hospital-based resources for
the care of the injured.8 A seemingly subtle name change to this document occurred
in 1990, renaming the iteration as Resources for Optimal Care of the Injured Patient in
an effort to account for more than just the hospital resources needed.9 This “bible” of
trauma center resources is now in its eighth edition (2014). The first trauma unit in the
United States was opened at the University of Maryland by Dr R. Adams Cowley in
 Trauma Systems 949

1961.10 Shortly thereafter, additional hospitals followed suit by opening their own
trauma centers. Dr Robert Freeark and Dr Robert Baker organized the opening of a
trauma unit at Cook County in Chicago in 1966.11 Under the guidance of Dr George
Sheldon, the University of California San Francisco General Hospital received both
a trauma center designation and a large multidisciplinary research grant in 1972.12
The development of academic departments of surgery with a strong interest in car-
ing for the injured patients and its related research was stimulated by the growing
recognition of a need, but also by the return to civilian life of surgeons from the Korean
War and the Vietnam War. A critical motivation was also a landmark report by the Na-
tional Academy of Sciences’ National Research Council entitled, “Accidental Death
and Disability: The Neglected Disease of Modern Society.”13 This was published in
1966 and examined the prevalence and need for organized trauma care. The investi-
gators highlighted the urgent need for improved organization, resource allocation,
data collection, research, and education in the comprehensive management of injured
patients.13 Congress responded to this report by passing the National Highway Safety
Act of 1966, which identified and funded changes to improve the communication, co-
ordination, and transportation of injured patients after motor vehicle accidents.5
Maryland, Florida, and Illinois used this opportunity to create some of the first orga-
nized trauma systems, which more formally integrated prehospital transport within an
interconnected system of trauma centers. In Maryland, this took the form of a coop-
erative organization between the University of Maryland, the Shock-Trauma Center
in Baltimore, the state police, helicopter crews, and prehospital providers. Implemen-
tation of this cooperative resulted in a marked reduction in mortality.14 Jacksonville,
Florida, instituted similar systems to improve prehospital care and coordination be-
tween prehospital providers and hospitals, with a demonstrated 38% reduction in
vehicular deaths.15
Illinois is credited with creating the first statewide trauma system in the early 1970s,
which included governmental support and leadership from the governor himself. The
Illinois system identified 5 key components for a trauma system: designated trauma
centers, special trauma training for providers, ambulance design for safe transport
of injured patients, technology to allow immediate communication between providers,
and constant reevaluation of care via trauma registries.11 In 1971, Illinois became the
first state to legislate the designation of trauma centers. Review of the Illinois out-
comes in 2 studies demonstrated improved mortality among patients treated in
trauma centers after the implementation of legislated trauma systems, whereas mor-
tality rates among injured patients treated at undesignated centers remained con-
stant.16,17 When these data were examined by region, a much more dramatic
improvement in mortality was noted among patients injured in a rural setting, demon-
strating the importance of access to prompt and high-quality trauma center care.17
The demonstrated mortality benefit of trauma systems in Maryland, Florida, and Il-
linois prompted additional legislation that fueled further development. The Emergency
Medical Services Systems Act of 1973 granted approximately $300 million for the
development and operation of statewide emergency medical services (EMS) systems
with a focus on ensuring improved rural access to specialized emergency care.5,18
These EMS geographic boarders defined following this act are still used as the current
EMS regions and agencies in all states, and typically are the beneficiaries of money
directed at emergency medical care and devices. This act remains a large reason
why EMS agencies exist and have modern equipment, even in rural settings.
As EMS services improved and expanded, the need for more formalized hospital
designations became apparent. The idea of rating or categorizing emergency depart-
ments was first discussed by the National Academy of Sciences at their 1966 National
950 Pigneri et al

Research Council meeting. It was not until 1971 that the American Medical Associa-
tion Commission on EMS formulated a system of designation based on emergency
department capabilities.19 Five years later, the COT published the first iteration of
Optimal Hospital Resources for Care of the Injured Patient, which defines the key
components of a trauma center and stressed the importance of a trauma center’s
function within a trauma system. These fundamental elements of a trauma system
remain the accepted standard today and include injury prevention outreach; access
to trauma care; prehospital triage, care, and transportation; acute hospital care at
capable centers; rehabilitation services; and ongoing research (Resources for optimal
care of the injured patient 2014).
In the 1980s, a series of articles was published that fueled the public’s demand for
the growth of trauma systems. As noted previously, the efficacy of trauma centers had
been demonstrated in Maryland; Jacksonville, Florida; and Illinois systems.
Conversely, as the efficacy of trauma systems was coming to light, the inadequacy
of medical care in areas without trauma systems was sorely noted. In the late 1970s
to mid-1980s, 3 areas specifically noted and studied this disparity in health care as
related to preventable death rates. West and colleagues20 published a landmark
article in 1979 demonstrating dramatically worse outcomes in Orange County, Califor-
nia, when compared with San Francisco, California. At the time, no formalized trauma
system existed in Orange County, and all injured patients were taken to the closest
available hospital. In contrast, severely injured patients in San Francisco were directed
to a single, central Level I trauma center. Despite the Orange County patients having
been younger and less injured, outcomes were markedly worse. In the cases reviewed
during the study period, 1.1% of trauma deaths were deemed potentially preventable
in San Francisco, whereas 28% of the central nervous system (CNS) injury deaths and
73% of the non-CNS deaths were deemed potentially preventable in Orange County.
The study cited lack of organized trauma care, lack of structured resuscitation, and
lack of aggressive surgical intervention for injured patients as the cause of this
disparity in outcomes.20 With assistance of local government, a trauma system was
implemented with subsequent improvement in trauma outcomes.21
In 1983, poor outcomes were reported in Portland, Oregon, and implementation of a
trauma system was suggested. Oregon’s government responded by instituting a
statewide trauma system, with a strategic designation of trauma centers. Two ele-
ments of Oregon’s approach to trauma system creation were novel at the time. First,
they declined several of the centers that applied for trauma center status. Second,
they expanded their network to include rural centers, which were designated as Level
IV centers. Through this, they were able to widen their catchment area while concen-
trating high-level trauma care into fewer, more specialized centers.5
The success of the Oregon trauma system encouraged its neighbor, Washington
State, to examine the health care of its injured patients, which identified enough prob-
lems to motivate the legislature of Washington State to fund an analysis of trauma care
system design and implementation, which was completed in 1987. This, in turn, led to
the creation of the Washington State trauma system under the direction of the State
Department of Health, which remarkably was passed unanimously into law in
1990.22,23
Following similar reports of unacceptable trauma outcomes, San Diego County also
developed a regionalized trauma center (1 Level I center, 4 Level II centers, 1 pediatric
trauma center, and an EMS network) in 1984. A follow-up study conducted by Shack-
ford and colleagues24 reviewed the trauma outcomes data for the 12-month period
following implementation of this new regionalized system. The investigators demon-
strated a marked increase in survival among the most critically injured trauma patients
 Trauma Systems 951

when treated within their trauma system. Specifically, survival among severely injured
blunt trauma patients increased from 18% to 29% and survival for severe penetrating
injuries increased from 8% to 20%.
Simultaneous to the development of these trauma systems was a call from
Congress for a follow-up evaluation of trauma outcomes nationwide. The resulting
report, Injury in America: A Continuing Public Health Problem,25 was published in
1985 and demonstrated that despite the improvements that had been seen within in-
dividual trauma systems, traumatic injury remained a significant threat to public health
on the national scale. In addition to benchmarking trauma outcomes, the report advo-
cated for increased efforts related to traumatic epidemiologic studies, injury preven-
tion outreach, and research focused on rehabilitation.25 Following publication of this
report, the Center for Injury Control was founded and established as a branch within
the Centers for Disease Control and Prevention (CDC).5 This followed considerable
discussion and debate on the appropriate federal funding home for trauma research,
with many advocates disappointed that the National Institute of Trauma Research
within the National Institutes of Health was not funded. This proved to be prophetic,
as in 1996 (Public Law 104–208) the CDC was barred by Congress from funding
gun-violence research programs, and shortly after drifted entirely away from funding
clinically relevant trauma-related research.
In 1987, West and colleagues26 conducted a national survey to determine the level
of ubiquity of trauma systems in the United States. EMS directors, health department
authorities, and state chairpersons on the COT from each state were contacted. All 50
states and the District of Columbia responded. Eight criteria were used to assess ad-
equacy of the trauma systems. These included (1) the presence of a governing agency
with legal authority to designate trauma centers; (2) the use of a structured process for
designation of trauma centers; (3) the use of the ACS COT standards for trauma cen-
ters; (4) the use of a geographically remote survey team in trauma center designation;
(5) restricting the number of trauma centers in an area based on community need; (6)
written triage criteria that guide transport of injured patients to designated trauma cen-
ters; (7) ongoing assessment of trauma centers; and (8) statewide trauma center
coverage. Only 2 states, Virginia and Maryland, were found to have complete trauma
systems with statewide coverage.
In 1990, the Trauma Care Systems and Development Act (Public Law 101–590) allo-
cated development grants to a total of 35 states for initiation of a new trauma system
or revision of an existing system.18 This federal legislation was in response to the
statements from some states and EMS regions that they could not afford to develop
the infrastructure of a trauma system. At the same time, it was also evident there was
considerable pressure from individual hospitals, agencies, and physician groups to
forgo trauma system development due to concerns regarding loss of autonomy,
excess governmental oversight of clinical practice, and the cost of meeting the re-
quirements of a trauma centers. The progress of trauma system development was
also thwarted by declining health care reimbursements and a change to diagnosis-
related group (DRG) payment system. This resulted in equivalent reimbursement for
acute care hospitals compared with trauma centers, despite patients with higher
severity of a given diagnosis being cared for at Level I centers. Referring hospitals
could now cherry-pick the most profitable cases, passing along those patients who
would require greater resource consumption without a compensatory adjustment in
reimbursement. The result was increased cost of care provided at Level I centers
with unadjusted reimbursement.5
An analysis of cost in New York State demonstrated that trauma patients in the
same DRG cost $27.5 million more when compared with nontrauma patients.27 A total
952 Pigneri et al

of 61 regional trauma centers shut down between 1988 and 1991, with an additional
center closing later that decade.28 Inadequate reimbursement was cited as a major
cause of trauma center closure.29 Centers that downgraded from trauma center status
could continue to care for patients with lower severity of injury, while transporting the
higher-severity patients within a given DRG to Level I centers, thereby compounding
the problem. Additionally, Level I centers were caring for a disproportionate number of
self-pay and Medicare/Medicaid patients when compared with community hospitals,
leading to even further reimbursement disparity.27
Being involved in the care of the injured as non-Level 1 centers would allow lower-
level centers to “transfer up” those patients who cost the most to care for, and often
(usually) had inadequate insurance/reimbursement resources. Hence, there was, and
remains, a financial incentive to be a lower-level trauma center within a community
that generally has a higher income and better insurance penetration as long as a Level
I center is nearby. These centers are able to care for mildly injured patients and are not
required to accept the severely injured in the same way that Level I centers are. This
may continue to contribute to the proliferation of Level II and III centers in states
without the governmental ability or will to regulate trauma centers, one of the tenets
of the original Health Resources and Services Administration (HRSA) trauma system
design document. As demonstrated in Florida, increasing the number of trauma cen-
ters alone does not improve the quality of care provided to injured patients within a
community. Rather, improving care relies on providing access to seasoned trauma
centers with adequate volume of trauma experience to continually adjust and improve
treatment paradigms.30
As the landscape of trauma care changed in the 1990s, the need for an increased
focus on systems of trauma centers became apparent. Despite guidance from the
ACS COT regarding optimal resources within each individual hospital designated
as a trauma center, there was little national guidance regarding the creation and or-
ganization of the larger trauma systems themselves. This decision making was left to
individual states and EMS systems. To address this need, HRSA released their
Model Trauma Care Systems Plan in 1992, which hoped to serve as a template for
each individual state during the process of trauma system development or adjust-
ment. This document stressed the importance of consistent legislative and financial
support, and cited the lack of these elements as key to the failure and closure of
many trauma systems and centers. A follow-up study was conducted by Bazzoli
and colleagues18 to evaluate the progress of trauma development in the early
1990s. A 23-page questionnaire was sent to existing trauma systems. The questions
included in the questionnaire were designed to address the 8 components of a
trauma system addressed in the 1987 study by West and colleagues.26 Only 5 states
(Maryland, Florida, Nevada, New York, and Oregon) were found to have complete
statewide trauma systems. This demonstrated only a modest improvement since
the 1987 study by West and colleagues.26 Notably, the most common deficiency
was the failure to regulate the number of trauma centers within the statewide system,
likely secondary to the financial incentives for Level II and III centers. This specific
deficiency was responsible for Virginia being removed from the list of complete
trauma systems.
Despite the advancements made in civilian trauma system organization over a
quarter-century, medical support for America’s first armed conflict since the Vietnam
War fell short of expectations in 1992 with Operations Desert Shield and Desert Storm.
A report published by the Government Accountability Office that same year indicated
how the military had fallen behind its civilian counterparts in developing a mature sys-
tem of regionalized trauma care (GAO/NSIAD-92–175, 1992).31
 Trauma Systems 953

In 1996, Michael DeBakey delivered a lecture at the 50th Anniversary Meeting of the
Society of Medical Consultants to the Armed Forces in which he challenged civilian
and military medical experts to remain vigilant and focused on the requirements of mil-
itary readiness. “I expect that you will be called upon should our nation ever face
another national emergency,” DeBakey said, himself a retired US Army Colonel. “I
know that you will be ready to accept that call, and I am confident that you will execute
your task at the highest level of excellence.”32
The military-civilian shared ideology that had been paramount in the early develop-
ment of trauma centers and systems would come full circle. In 2004, the ACS COT
would prove instrumental in the US military’s development of the largest trauma sys-
tem in the world to support the wars in Iraq and Afghanistan. Spanning more than 9000
miles, the Joint Theater Trauma System was the culmination of trauma system devel-
opment in the early twenty-first century. Based on the ACS COT’s Resources for
Optimal Care of the Injured Patient,9 the system incorporated data-driven resource
distribution intended to efficiently sustain multiple high-intensity, open-ended con-
flicts. The plan also required the Joint Theater Trauma Registry to collect, organize,
analyze, and distribute casualty information from the point of injury through evacuation
to definitive care stateside for the purposes of research, performance improvement,
and quality assurance. A library of clinical practice guidelines was also developed
and distributed in an effort to standardize evidence-based best practices throughout
various levels of casualty care. The system collectively reduced the mortality rate of
combat casualties to less than 9%, roughly half that observed in the Vietnam War
when trauma systems were in their infancy.
The benefits of well-orchestrated trauma systems extend beyond mortality statis-
tics. In combat, they exert confidence in the fighting soldier. For civilians, they impart
a similar perception of safety that influences the way communities thrive. HRSA pub-
lished a report in 2002 citing public support, and the resultant state and federal sup-
port, as a mandatory element for the success of civilian trauma system growth and
development (Fig. 1). A follow-up report by Champion and colleagues33 published

Fig. 1. Timeline of assessments relevant to civilian trauma research. (From National Acade-
mies of Sciences, Engineering, and Medicine. A national trauma care system: integrating
military and civilian trauma systems to achieve zero preventable deaths after injury. Wash-
ington, DC: The National Academies Press; 2016; with permission.)
954 Pigneri et al

in 2006 demonstrated several prominent public misconceptions regarding the state of

trauma systems of care. First, nearly 90% of Americans polled felt that an organized
and coordinated system for the delivery of trauma care should exist and be a priority.
Nearly two-thirds of Americans were confident that such a system existed near them,
such that they would receive this care if they were injured. Additional findings included
more than 60% of Americans being unaware of the prevalence of death from serious
injury and the prevalent misconception that a formalized trauma system existed in
every state. However, at the time, only 8 states were deemed to have complete state-
wide systems for trauma care. This knowledge gap by the general public is likely
responsible for the lack of consistent state and federal prioritization of the develop-
ment and constant improvement of trauma systems.
In 2006, HSRA released Model Trauma System Planning and Evaluation, their
updated version of the 1992 Model Trauma Care System Plan2 and one that presented
trauma as a public health problem. This document specified the discrete element of a
trauma system, to which the ACS COT references during their discussion of trauma
system dynamics. The 3 key functions of a trauma system defined within the Model
Trauma Systems Planning and Evaluation report are ongoing assessment of injury
epidemiology, policy development focused on protecting the public from injury, and
ensuring high-quality care through regulation. The 10 services essential to achieving
these 3 functions are (1) constant monitoring of the community health status and
needs; (2) diagnosis and investigation of public health issues and hazards; (3) public
engagement through education and empowerment; (4) community partnerships
aimed at diagnosing and treating local health problems; (5) development of policies
that support identified health care needs; (6) enforcement of laws and regulations
designed to ensure health and safety; (7) a network for linking patients to their needed
health resources with a route for access to care that may be locally unavailable; (8)
quality assurance of the health care work force; (9) ongoing assessment of the effec-
tiveness, accessibility, and quality of health services rendered; and (10) research ini-
tiatives to seek new solutions to current health problems.
A ubiquitous, effective, and efficient EMS service is inherent to the ability of any
trauma system to meet the previously listed criteria. Like police departments, fire de-
partments, and EMS services, trauma systems can arguably be considered a commu-
nity need, funded and regulated like these other public health entities. EMS not only
provides the initial assessment and stabilization of injured patients, but they also
decide to which hospitals patients will be taken. Triage to the level of care appropriate
for the definitive management of a patient’s injuries may conflict with the immediate
need for stabilization and geographic. For this reason, field triage criteria were devel-
oped in tandem with trauma system growth.34 These algorithms also require frequent
reassessment and amendment to ensure appropriate attention to the needs of the
community served.
Although room for improvement of trauma systems remains, the national improve-
ment in trauma care through the development of regionalized trauma systems has
been clearly demonstrated.35 Additionally, this improvement has not been without
notice from outside sectors of the medical community. Perhaps the most notable
endorsement of this success comes from the trend toward regionalization of other as-
pects of medical care. Over the past few decades, there has been a national push for
regionalization of cardiac care, acute stroke treatments, cancer diagnosis and treat-
ment, and bariatric surgery care. These fields have aimed to create regionalized sys-
tems not unlike the regionalized trauma systems platform. In a similar manner to
trauma, these sectors aim to concentrate specialists in the field into centers of excel-
lence. These centers are often chosen in areas with the best access to epidemiologic
 Trauma Systems 955

data, most current systems of care, and a high degree of ongoing research aimed at
finding innovative treatments for their specific health challenges. The American Heart
Association (AHA) has taken this 1 step further and in 2010 called for a regionalized
system more extensive that a system of centers of concentrated care providers.
The AHA called for a regionalized system to include EMS in the stabilization and triage
of patients who suffer cardiac arrest outside of the hospital. In this call-to-action
address, improved outcomes with coordinated trauma systems was used as evidence
that regionalized systems improve care.36,37
What is next for trauma systems? Can they be improved, or are the economic forces
too powerful to allow regionalization of health care? The care of patients injured in a
rural setting has long presented a unique challenge. Population concentration in these
regions does not support the development or sustainment of Level I centers in these
regions. Yet time from injury to definitive treatment remains an undeniable factor in
trauma outcomes. The historic approach to this unique problem has been to expand
the catchment net for urban-based trauma systems. However, this approach has led
to a large volume of mildly or moderately injured patients being transferred to urban
Level I or II centers. When patients are over triaged to these urban centers, a reason-
able amount of emotional and financial distress can be created for the patient and
family. The message is relayed to the family that their loved one is so gravely injured
that he or she requires triage to a high level of trauma care. Additionally, emergency
travel to urban centers may be inconvenient, expensive, or dangerous for elderly or
emotionally distraught loved ones. Historically and currently, rural centers are trained
to provide initial stabilization and rapid transfer for injured patients who present at their
door. This should remain true and mandatory for severely injured patients or patients
whose needs exceed the care available at the receiving hospital. However, most
injured patients are mildly injured and do not require such transfer. Improved commu-
nication between EMS providers and receiving hospitals may allow us to spare a large
number of patients from unnecessary transfer.38
Another challenge facing the success of trauma system design and implementation
is the unregulated opening of trauma centers, most notably Level II trauma centers. In
states and regions that fail to control the number and distribution of trauma centers,
there has been a proliferation of trauma centers near populations that generally
have a higher socioeconomic status, are more insured, and have a low volume of
penetrating trauma. This has led to the decrease in patient volume in the Level I center,
along with decreasing reimbursement that jeopardizes the existence of the Level I
center. Unlike the trauma center crisis 1989 to 1991, this is the result of high reim-
bursement for Level II trauma centers, that then want to keep patients, with the resul-
tant loss of volume for training and experience with uncommon injuries, as well as
income, for the Level I centers.39 Notable examples are Florida, Colorado, and
Texas.40,41
In August 2015, the ACS COT convened a consensus conference to develop the
Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining
the number of trauma centers required for a region42 (Table 1). Although legislative au-
thority to determine the number and need of trauma centers has been an essential
component of trauma system design since 1992, it has, until the most recent decade,
been largely unnecessary, as most hospitals did not want to participate in trauma care.
This is changing and bringing new challenges to trauma system survival.2
The background for this changing approach to trauma care and the view of the ACS
COT are nicely outlined in a discussion (by Mike Rotondo) of the article by Uribe-Leitz
and colleagues,43 the only peer-reviewed publication to date on the use of this tool
and the source of Table 1. The NBATS tool is available on the ACS Web site
956 Pigneri et al

Table 1
NBATS criteria and assumptions used for NBATS model for missing data source

Assumptions
Base Lower Higher
Range of Possible Points Case Range Range
1. Population size 2–10 N/A N/A N/A
2. Median transport times 0–4 0 0 4
3. Community support 0–5 0 0 5
4. Number of patients with 0–4 0 0 4
ISS >15 at nontrauma centers
(non-Level I/II or III centers)
5. Number of Level I, II, or III 0 to negative number N/A N/A N/A
trauma centers based on multiplier
6. Estimated number of 2 to 2 0 2 2
patients with ISS >15 based
on number of trauma
centers vs actual number
seen at Level I/II centers

Abbreviations: ISS, injury severity score; N/A, not applicable (no missing data); NBATS, Needs-Based
Assessment of Trauma Systems.
From Uribe-Leitz T, Esquivel MM, Knowlton LM, et al. The American College of Surgeons needs-
based assessment of trauma systems: estimates for the State of California. J Trauma Acute Care Surg
2017;82(5):861–6; with permission.

(https://www.facs.org/quality-programs/trauma/tscp/nbats; accessed June 13, 2017)

as well as documents that include the list of participants and some introductory
notes.44 The tool assesses 6 specific factors, assigning positive or negative points
to each factor. These factors are as follows:
1. Population size
2. Median transport times
3. Lead agency/community support presence
4. Severely injured not cared for at any trauma center
5. Number of current Level I centers
6. Number of severely injured seen at a Level I and II trauma center already in the
system
Criticisms of this tool are that by including both Level I and II in the final point, the
tool fails to make the distinction of care (or costs, or margin) between these 2 types
of trauma centers, and that it does not reward volume performance, nor the impor-
tance of training and teaching. The more points on this tool scale, the more trauma
centers a region should have, again, not differentiating between Level I or II
centers.
This tool was largely developed from discussions that had been occurring in
Florida, and as a result, this tool lacks any legislative authority to implement
the suggestions based on its results. The ACS COT has deferred any authority
to deciding which hospitals should be trauma centers based on need, allowing
that the local regulatory agencies of the EMS services should have that authority,
and if they are unwilling, the ACS COT lacks the authority. In many regions, it
would appear that the current state of trauma system design and hospital desig-
nation is based on political pressures, economic factors, and last, on patient
need.
 Trauma Systems 957

In the age of technology, there is certainly room for technological advancements

aimed at improving communication among EMS, receiving hospitals, rehabilitation
centers, and long-term providers. An integrated electronic medical system (EMR)
could allow trauma specialists at Level I centers to review imaging and prepare for
a patient before the patient’s arrival, expediting the delivery of time-sensitive care.
The same system could allow trauma surgeons to follow patients or opine on critical
events that occur after patients have moved to rehabilitation facilities. EMS crews
enabled with video-conferencing technology would allow physicians to drive decision
making regarding triage and field care when needed. A nationally integrated EMR sys-
tem based on permanent patient identifiers, such as fingerprints, could allow immedi-
ate access to patient history in the trauma bay, which would likely prove most useful
for our elderly and comorbid patients. In rural and geographically difficult to access
regions, video-enabled drones could allow for early assessment and triage planning
before EMS crew arrival at the scene. The degree to which these changes will influ-
ence patient outcomes remains to be seen. However, the previously documented out-
comes improvement when patients are managed by trauma specialists at Level I
centers would argue that these specialists driving other areas of decision making dur-
ing other vulnerable phases of care would likely lead to similar improvements. The pri-
mary obstacle to a technology-rich fully integrated national trauma system will likely be
the need for layered mechanisms for protection of personal health information. Addi-
tional issues may be encountered at the interface between existing EMR systems. As
we push forward, overcoming these obstacles may prove worthwhile if we are better
able to use the golden hour, improve communication between providers, and ensure
patient safety through their period of rehabilitation.
The evolution of trauma care in America is far from over. As new weapons reach the
streets and we step into a time of political uncertainty, the specific challenges that lie
ahead remain unknown. We must ask ourselves how our past experiences impact our
vision for the care of injured patients now and in the future? An ideal state would be
formulated through a network of highly functioning and interconnected trauma sys-
tems that provide complete coverage to the entire United States without significant
redundancy or overlap. Such a system would require a consistent source of financial
support for both ongoing operations as well as research and development. Innovative
technologies would focus on improved communication between phases of care to
create a truly integrated experience at the level of each individual patient. Such a sys-
tem would require governmental oversight and regulation, specifically related to
restricting the number of trauma centers to those truly needed within each individual
trauma system to meet the community need. Continued data collection within each
trauma center, within each trauma system, and within larger cohorts, such as the Joint
Theater Trauma System and national Trauma Quality Improvement Program, will be
necessary to continue improving the routes through which care is provided. Finally,
improved public awareness and support would serve as the backbone on which our
efforts rest.

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