1 EVOLUTION OF THE TRAUMA CYCLE
Incidents of trauma occur in epidemic proportions in our society today; however, this is not a new phenomenon. Traumatic injury has been recognized as a part of the human experience since early civilization. Anthropologic studies of the bony remains of Neanderthal humans have shown that members of this group sustained a great deal of trauma during their lifetimes.1 Disfigured skeletal structures and long-term bony calcification are evidence that the trauma they experienced was a result of their relatively dangerous lifestyle. Many injuries were sustained as a result of constant exposure to the raw elements of nature, including frequent encounters with wild animals.
Although the concept of traumatic injury as a recognized societal affliction has remained unchanged since the time of the Neanderthals, the incidence, magnitude, cause, mechanism, and treatment of traumatic injury have changed. Human interaction with the environment at given points throughout our life span and the effects of a variety of forces—industrialization, societal influences (including belief systems), and educational orientation and level—have influenced the ways in which injury occurs in our society today. Currently, traumatic injury is a major public health problem in the United States and the world, and the incidence of traumatic injury is predicted to increase worldwide in the twenty-first century.
TRAUMA SYSTEMS DEVELOPMENT
Trauma is one of the major challenges in emergency, critical care, intermediate care, acute care, and rehabilitation nursing practices today. To recognize and develop a keen appreciation for trauma nursing as a specialty field, one must not only examine state-of-the-art practices but also review the historic events that led to the creation of a systems approach to care and to the development of the clinical knowledge base that has formed the foundation for this distinct area of clinical nursing practice.
The term trauma is used to describe a variety of injuries, and the concept of trauma embodies several associated terms—shock, injury, accident, accidental injury, fatality, and casualty. These terms are sometimes used synonymously and may be used interchangeably throughout this book, although use of the term accidental is avoided when possible because it implies that an event is unexpected or unavoidable. Over the years a deeper understanding of the underlying causes of traumatic injury has led to the belief that most unintentional events are predictable and therefore preventable.
MAGNITUDE OF THE PROBLEM
In the United States, unintentional injury is the most common cause of death for individuals aged 4 to 44 years.2 The National Safety Council reported that unintentional injury continues to be the fifth leading cause of death for all ages, exceeded only by heart disease, cancer, stroke, and chronic lower respiratory diseases.2 The primary causes of unintentional injury are as follows:
Although ranked fifth as the cause of death for all age groups, injury is the leading killer of one of our nation’s most valued resources—young people. Children and youths between ages 5 and 24 years have a greater chance of dying from unintentional injury than from any other cause, and more than three of four individuals in this age group who die from injury are male.2
In 2003, nonfatal injuries that affect millions of Americans caused about 1 out of 12 people to seek medical care and 2.8 million to require hospitalization.2 The economic impact of both fatal and nonfatal unintentional injuries was estimated to be $574.8 billion in 2004.2
The Centers for Disease Control and Prevention (CDC) reports that trauma is estimated to cause more than 161,000 deaths in the United States annually.3 According to the National Highway Traffic Safety Administration’s (NHTSA) National Center for Statistics and Analysis for 2005, 43,443 people were killed in motor vehicle crashes. This translates into one person killed in a vehicular crash every 12 minutes.4 This report ranks motor vehicle crashes as the leading cause of death for people aged 4 to 34 years.
In contrast, the fatality rate per 100 million vehicle miles of travel decreased from 1.73 reported in 1995 to 1.47 in 2005.3 The NHTSA report credits an 82% rate of safety belt use nationwide and a reduction in the rate of alcohol involvement in fatal crashes (39% in 2005, down from 42% in 1995) as significant factors in lowering the fatality rate. Motor vehicle crashes remain an economic burden from loss of life, disabilities from injury, and costs of property damage. The economic cost alone of motor vehicle crashes was reported to be $230.6 billion in 2000.4
The CDC’s National Center for Injury Prevention and Control cites falls as the most common cause of nonfatal unintentional injury for people aged 35 through 65+ years.3 Falls are the main cause of unintentional injury deaths for people 78 years old and older and the second cause of unintentional injury death for people aged 65 to 74 years.2 Falls and motor vehicle incidents are the leading cause of nonfatal injuries treated in hospital emergency departments (EDs). About 8 million people were treated in EDs for fall-related injuries in 2003.2
The age-adjusted unintentional injury death rate declined by 59% per 100,000 people from 1912 to 2004.2 During this same period, the nation’s population tripled. The decrease in motor vehicle–related deaths during the past 86 years is in part due to the development of emergency medical systems, trauma care systems, advances in surgical and critical care, and improvements in road design, enhanced vehicle safety features, and increased use of driver and passenger restraints.
About 35% of all visits to EDs in the United States were injury related in 2003.2 The substantial economic impact of both fatal and nonfatal unintentional injuries amounted to $574.8 billion in 2003.2 This cost is described as equivalent to the following:
• 72 cents of every dollar paid in federal personal income taxes or
• 50 cents of every dollar spent on food in the United States2
All citizens are burdened by this cost, whether out of pocket, through higher prices for goods and services, or through higher taxes and user fees.
In addition to the human loss and disability resulting from trauma, the economic cost also must be addressed. The National Safety Council defines a disabling injury as one that results in some degree of permanent impairment. This includes injuries that render a person unable to effectively perform regular duties or activities for a full day beyond the day of the injury. Cost estimates therefore include the following:
• Insurance administration costs
• Property damages in motor vehicle crashes
• Indirect work loss (Indirect loss from work injuries is the money value of the time lost by noninjured workers, including time spent filling out reports or giving first aid to injured workers and time lost as a result of production slowdown.)
Despite an alarmingly high incidence of unintentional injury over the years, the significance of this problem has not always been recognized by the public. The first sign that this issue had reached the level of national politics appeared in 1960 when John F. Kennedy, during his presidential campaign, issued a statement acknowledging that “traffic accidents constitute one of the greatest, perhaps the greatest, of the nation’s public problems.”5 Since that time, attention has been directed toward raising public awareness about this sizable problem. Concurrent efforts have been made to identify fundamental elements that would render the nation’s health care delivery system more responsive to the needs of those who have sustained traumatic injury. Over the years, greater effort has been focused on injury prevention. However, this area still requires further funding and research.
THE MILITARY EXPERIENCE
Before the 1960s, advances in caring for the critically injured were made primarily by the military. Injuries sustained by military personnel and civilians during war were the primary focus of studies on traumatic injury and shock. These study findings became the initial source for information regarding the treatment of traumatic injuries.
In 1916, during World War I, the U.S. National Research Council of the National Academy of Sciences formed a Committee on Physiology, whose Subcommittee on Traumatic Shock began to collect, review, and analyze objective data regarding the physiology of circulation and its relationship to the various models that had been defined for the study of shock.6 This was the first coordinated prospective study organized for the purpose of obtaining a better understanding of the body’s responses to severe trauma. The information from these studies was discussed at formal meetings and conferences, which resulted in a more widespread dissemination of knowledge about shock resulting from traumatic injury. Although by the mid nineteenth century the term shock began to be applied to the clinical state of individuals who had sustained severe trauma, the nature of clinical shock remained a mystery.6
During World War II, the care of patients who had undergone trauma and the understanding of the nature of shock improved significantly. This was due largely to the prompt application of information obtained by the Medical Board for the Study of the Treatment of the Severely Wounded. This 22-member board was appointed on September 3, 1943, by the Theater Commander, Lt. General Jacob B. Devers, and was made up of medical officers, nurses, technicians, and support personnel who worked as a research team.6 This team responded to any medical request from the field and compiled casualty data during an 8-month period in Italy. The data from observations of 186 military casualties comprised the first volume of the historic series by the Medical Department of the United States Army. It was titled Surgery in World War II: The Physiologic Effects of Wounds.7 The information obtained by the board was disseminated not only in the field hospitals that were treating and studying the wounded but also throughout the front line and in base hospitals. The study results were impressive and led to a change in policy regarding the treatment of hypovolemic shock. Resuscitation practices improved as hemodynamic alterations became better understood and knowledge about posttraumatic renal failure, an often fatal complication of severe shock, emerged.
A similar but more extensive program was established during the Korean War (1950-1953) and later during the Vietnam War (1957-1975). The research efforts put forth during World War II by the Medical Board for the Study of the Treatment of the Severely Wounded continued and was strengthened by a newly established Surgical Research Team. This was made possible in part by the support services that had been made available from stateside organizations and institutions in the form of high-tech equipment sent to the combat zone. The emergence of the research team represented a significant achievement for military medicine during the twentieth century. Research findings of the team contributed to further refinement of care delivered to trauma patients during the Korean War. Through these efforts, progress was made in the clarification of the hemodynamic disturbances that occur with different forms of traumatic injury, and extensive knowledge was gained about organ function and the metabolic disturbances in shock and acute circulatory failure.
The pressing demands of surgery during war, coupled with the advances in medical care that occurred during the previous century, contributed in part to the improved trauma care outcomes that were realized during the Vietnam War. Improvements in field resuscitation, increased efficiency of transportation, and aggressive treatment of war casualties proved to be major factors contributing to life-saving endeavors. The death rates of war casualties reaching designated facilities decreased from 8% in World War I, to 4.5% in World War II, to 2.5% during the Korean War, to less than 2% in the Vietnam War.8
Experience in caring for battlefield injuries sustained during the wars in Iraq and Afghanistan also offers new knowledge and expertise that can help to improve treatment outcomes for the injured. For example, a large number of military personnel have been exposed to blasts causing significant injuries, particularly affecting the brain. This has prompted investigations into how to best care for victims of blast injuries and development of evidence-based Guidelines for Field Management of Combat-Related Head Trauma.9 Further knowledge about the effectiveness and risks of agents such as factor VIIa used to stop bleeding are also being realized. These and other revelations made during wartime can be considered to assist in determining the best trauma care for those injured and cared for on and off the battlefield.
THE MILITARY INFLUENCE
Over time, it became clear that our national health care delivery system needed changes on the basis of what had been learned during wartime about the significance of time in saving lives and about the physiologic responses to injury. The need for an effective system to care for the severely injured was just as pressing in the civilian sector as in the military arena. As had been demonstrated consistently during wartime, rapid evacuation of the seriously injured from the battlefield to advanced treatment stations (mobile army surgical hospital units), which were equipped with necessary supplies and staffed with highly skilled personnel, saved lives. Although long overdue, the principles on which this system was designed have since been found to be easily transferable to and as effective in civilian life.
The modern era of a civilian systems approach, which focused on more efficient emergency health care for the injured, began in 1966 with the publication of a document by the National Academy of Sciences, National Research Council. This document, Accidental Death and Disability—The Neglected Disease of Modern Society, was a far-sighted approach to the development of an effective emergency medical services (EMS) system throughout our nation. It was the product of a 3-year study conducted by a committee on trauma, shock, and anesthesia in conjunction with special task forces from the Division of Medical Sciences, the National Academy of Sciences, and the National Research Council. The results were compiled after representatives from health care organizations reviewed the status of initial emergency care provided after “accidental” injury. The study groups reviewed a broad spectrum of factors, including ambulance services, voice communication systems, hospital EDs, and intensive care units, while incorporating research results in shock, trauma, and resuscitation. On the basis of identified deficiencies, the general areas of consideration recommended by the committee and outlined in the published document10 included the following:
• Emergency first aid and medical care
• Development of trauma registries
• Convalescence, disability, and rehabilitation
• Care of casualties under conditions of natural disaster
The national effort for establishing an improved emergency health care system and much of the basic framework on which the nation’s EMS system has subsequently been built were presented in this document. This classic “white paper” represented the first major government report acknowledging that significant numbers of people were killed or disabled as a result of unintentional injuries in the civilian population, which was costing the nation billions of dollars each year. Contributing significantly to the high mortality and morbidity rates were the inefficiencies in the nation’s emergency health care delivery system. Unskilled health care personnel working with inadequate transportation and communication system policies and guidelines were taking the injured to facilities that were not sufficiently prepared to treat them. It became apparent that the problems of initial care and management of injured persons were similar in kind, although different in magnitude and scope, to those encountered by the military during periods of war. The time was right for the application of new knowledge and skills in caring for the injured.
EARLY PIONEERING EFFORTS
During the late 1960s and early 1970s, the need for a systematic approach to the care of the seriously injured patient became apparent. The initial efforts to design and develop emergency medical clinical delivery systems were based on the care requirements of specific types of injury (e.g., trauma, burns, and spinal cord injuries).10 The conceptual design of a systems approach required that effective medical and surgical treatment regimens be applied in situations other than the traditional in-hospital setting. This necessitated the reorganization of existing health care structures, the implementation of new technologies, and the development of educational programs so that clinical treatment modalities proven effective in the hospital environment could be applied and tested in the prehospital and interhospital phases. Physician-supervised educational programs and extrahospital emergency care programs began to emerge, with emergency medical technicians-ambulance (EMT-A) and advanced life support emergency medical technicians-paramedic (EMT-P) assuming key roles.11
In several parts of the country, hospitals were categorized regionally, and those with demonstrated expertise were designated as trauma, burn, or spinal cord injury centers. In Illinois, for example, the regionalization of emergency care for multiple and critical injuries was initiated and developed statewide in 1971. As the Illinois trauma program began to develop and mature, a program of patient transfer and burn center care also was initiated for the four burn units and major burn center (Cook County Hospital) in Chicago, which used a patient distribution program and central bed registry.12 In 1972, in collaboration with the Illinois trauma program, representatives from the Midwest Regional Spinal Cord Injury Care Systems at Northwestern Memorial Hospital and the Rehabilitation Institute of Chicago (McGaw Medical Center, Northwestern University) formulated a macroregional catchment program for acute spinal cord injuries.13 In 1973, the shock-trauma program of the University of Maryland, supported by the Maryland state government, was expanded statewide and became the Maryland Institute for Emergency Medicine (MIEM).14
These pioneering efforts were significant because they represented working models for further regional trauma/EMS systems development. The apparent successes resulting from these system designs became the catalysts for a more intense national effort to plan and implement improved trauma/EMS systems. In Maryland, the overall age-adjusted death rate and adverse effects from injuries has been declining steadily since the implementation and maturation of the statewide emergency medical and trauma care systems. The rate declined from 29.8 in 1988 to 26.5 in 2003.15 In comparison, the national figures for the same years were 35 and 36.1, respectively.15
FEDERAL SUPPORT OF TRAUMA/EMS SYSTEMS
Federal support of EMS started during the early 1970s, when congressional hearings were held to promote development of a comprehensive EMS law. In 1973, the Emergency Medical Services Systems (EMSS) Act was passed, which contained guidelines and specific technical measures that supported a nationally coordinated and comprehensive system of emergency health care accessible to all citizens. The identification of fundamental elements of the EMS system deemed necessary for the comprehensive care of the critically ill and injured was accomplished with this mandate. Included in the EMSS Act were 15 requirements (Box 1-1) that would assist EMS system project planners and health care professionals in establishing comprehensive, area-wide, and regional EMS programs.16
BOX 1-1 Emergency Medical Systems Act 1973 Requirements
• Use of public safety agencies
• Standard medical record keeping
• Consumer information and education
• Independent review and evaluation
The 1973 EMSS Act, with its subsequent changes in 1976, is considered one of the most important factors influencing the development of EMS systems throughout this country. This act focused on improving the nation’s emergency death and disability statistics by mandating that the emergency medical care programs that were federally funded by the Department of Health and Human Services (DHHS) must plan and implement a systems approach on a regional basis for emergency response and immediate care provisions. Although many emergency medical conditions had been identified, it was determined that the seven critical target patient care areas for regional EMS systems planning were major trauma, burns, spinal cord injuries, poisonings, acute cardiac conditions, high-risk infants and mothers, and behavioral emergencies. In-depth knowledge of the incidence, epidemiology, and clinical aspects of these categories is essential for appreciating a systems approach to regional planning and delivery of care. Much of this information, specifically that related to multiple traumas, spinal cord injuries, and burns, is explored in greater detail in this book.
The federal government withdrew from its lead role in EMS development in 1981 with the passage of the Reconciliation Act, which integrated the EMS program into the Health Prevention Block Grants and gave responsibility back to the states for direction and development of EMS. The General Accounting Office (GAO) report of 198617 disclosed the effect of this transition of EMS system programs from federal to state leadership under the block grant program, which concluded the following about a major sector of the United States (more than 50%):
• It lacked the usage and access to the universal phone access number 911.
• It lacked access to and use of advanced life support ambulance services in rural areas.
• It did not have any formal developed trauma care systems at all.
Senators Alan Cranston and Edward M. Kennedy first introduced legislation to address the recommendations of the 1986 GAO report in the 100th Congress in January 1987.
President Bush finally signed this legislation into law as Public Law 101-590 on November 16, 1990. This legislation, titled the Trauma Care Systems Planning and Development Act of 1990, is significant because it provided federal assistance for the development of emergency/trauma care systems throughout the United States. This Act amended the Public Health Services Act by adding a new title, Title XII. The act authorized the Department of Health and Human Services (DHHS), through the Health Resources and Services Administration (HRSA), to make grants to states for trauma systems planning and development. The major provisions of this act included the following18:
1. A council on trauma care systems. The purpose of the council is to report needs of the trauma care system and how states are responding to such needs. This council has 12 public members, including two nurse positions (one critical care position and one emergency medical training position).
2. A clearinghouse on trauma care and EMS. This is to be established by contract to serve as a collection, compilation, and dissemination point for information relating to all aspects of emergency medical services and trauma care.
3. Programs for improving trauma care in rural areas. Grants will be authorized for public and private nonprofit entities for research and demonstration projects that will improve the availability and quality of emergency medical/trauma care in rural areas.
4. Formula grants with respect to modification of state plans. Most of the appropriated funds (80%) will be allotted by formula for each state and territory. Beginning in the second fiscal year that states receive funds, they must make a matching nonfederal contribution (in cash or in kind) in specified ratios.
5. State plans and modifications. Each state must submit to the Secretary of Health and Human Services the trauma care component of the state’s EMS plan. The funds allotted for each state may be used only to make such modifications to the state plan as are necessary to ensure access to the highest quality of trauma care.
6. Trauma care standards and a model trauma care plan. Each state must adopt standards for designating trauma centers and for triage, transfer, and transportation policies. In addition, the Secretary must develop in the first year of this act a model trauma care plan that may be adopted for guidance by the states.
7. Data and reporting requirements. Each state must report annually to the Secretary the number of severely injured patients; the cause of injury and contributing factors; the nature and severity of the injury; monitoring data sufficient to evaluate the diagnoses, treatment, and outcomes of such trauma patients in each trauma center; and expenditures.
8. Technical assistance and supplies and services in lieu of grant funds. The Secretary shall provide technical assistance with respect to planning, development, and operation of any program carried out with the allotted funds, at no charge to the state.
9. Waiver. Under certain limited conditions, the Secretary may allow a state to use a percentage of allotted funds to reimburse designated trauma centers for uncompensated care.
The Trauma Systems Planning and Development Act was first funded with $5 million in fiscal year 1992 and for the following 4 years; however, in 1995 the 104th Congress rescinded most of the funding and did not provide any funding for fiscal year 1996. Senate Bill 1745 was passed in 1998, reauthorizing a number of public health programs, including the Trauma Systems Planning and Development Act. This legislation authorized the program through fiscal year 2002 and provided $6 million in funding for states to plan and develop organized systems of trauma care. This program provided grant funding to states to implement trauma systems and developed partnerships with stakeholders to promote trauma system development nationally. The program was closed out in March 2006 because no funds were appropriated (zeroed out) by the DHHS. This occurred because no funding was approved in the Education and Related Agencies Appropriations Act 2006 passed by Congress in December 2005.
As mandated by the Trauma Systems Planning and Development Act, a model trauma care plan was developed and published by HRSA as a template for states to use to design a local trauma system. This plan contained mandatory components necessary to meet the needs of all injured patients who require the services of an acute care facility. The plan stressed two important concepts:
1. The need for a trauma care system to be integrated into the overall EMS system
The plan classified the components as “administrative” and “operational and clinical.”
The administrative component included leadership, system development, legislation, and finance. The operational and clinical component included public information/education and prevention initiatives, human resources, prehospital care, EMS medical direction, triage, transport, definitive care facilities, interfacility transfer, medical rehabilitation, and evaluation.18 As a result of the 2002 appropriations for a division of trauma and EMS within the HRSA, a revision and update to the Model Trauma System Plan was published and released in February 2006.20 The revised document, Model Trauma System Planning and Evaluation, used a public health framework to address what a trauma system does, whereas the earlier Model Trauma System Plan addressed the components necessary for a trauma system.20 The new Model Trauma System Planning and Evaluation document contains a self-assessment for trauma system planning, development, and evaluation that can assist a state or region to perform an objective trauma system assessment and to define its system-specific health status benchmarks and performance indicators.20
TRAUMA/EMS SYSTEM DEVELOPMENT
As EMS systems have developed, the design seems to represent a composite of individual and unique systems of care for particular patient groups (e.g., multiple trauma, spinal cord injuries, burns). Although it is necessary for these systems to utilize common EMS components such as transportation, communications, and specialty skilled prehospital health team members, the care, resources, and facilities must be specifically designed for each patient group. EMS system components must be adapted to address and accommodate specific clinical needs if accurate and effective planning is to occur. The key EMS components for the trauma patient population are facilities categorization and trauma center designation (Table 1-1). For trauma patients, the establishment of triage and transfer protocols is critical to ensure that immediate intervention is consistent and decision(s) regarding transfer to a designated trauma facility for definitive care are facilitated. Thus it is of utmost importance that regional trauma/EMS systems plan and develop clinically sound trauma care programs on a geographic basis. Because of the complex requirements, the care of the trauma patient has provided an excellent model from which to design a basic health care delivery system. This has since been expanded to include other types of emergency medical conditions.21
From Boyd DR, Edlich RF, Micik S: Systems approach to emergency medical care, Norwalk, Conn, 1983, Appleton-Century-Crofts.
The clinical significance of the systems approach in developing a regional trauma/EMS system was clearly identified by the Division of Emergency Medical Services of the DHHS and reflected in their program guidelines.21 In congressional testimony, representatives of this agency described the unique clinical requirements of the patient with multiple trauma, the need for a regionalized system of care, and the key EMS system components crucial to a successful and efficient trauma care program (i.e., facilities, critical care units, and transfer of patients). Although it was believed that a trauma/EMS system must respond adequately to all declared emergency calls within its designated geographic region, which included nonemergency cases (80%), truly emergent cases (15%), and critical cases (5%),20 emphasis was placed on the need to identify effectively the critical patient whose chance of survival desperately depended on a competent trauma care delivery system. It was toward increasing the chance of survival for these critical patients that conceptual system planning and initial program development were directed.
In 1987, the American College of Emergency Physicians’ (ACEP) Trauma Committee published Guidelines for Trauma Care Systems.22 The ACEP guidelines state “trauma care represents a continuum that is best provided by an integrated system extending from prevention through rehabilitation and requiring close cooperation among specialists in each phase of care.”
In the 1976 report “Optimal Hospital Resources for Care of the Seriously Injured,”23 the Task Force of the Committee on Trauma of the American College of Surgeons called for hospitals to commit personnel and facility resources to caring for seriously injured patients. The original proposal, presented in the 1966 landmark document Accidental Death and Disability: The Neglected Disease of Modern Society, suggested that the categorization of facilities should be based on the individual institution’s capacity to handle a broad spectrum of emergency conditions.9 This plan—the implementation of a variety of categorization schemes—proved to be unsuccessful, and a more detailed set of guidelines was provided by the Task Force of the Committee on Trauma of the American College of Surgeons in 1979. This revised document, Hospital Resources for Optimal Care of the Injured Patient, replaced the 1976 report.23 Emphasis was placed on special problems of geography, population density, availability of community and regional resources and personnel, and the pervasive demands for cost-effectiveness, with the most significant element being commitment, institutional and personal. Institutional commitment was defined as the immediate availability of capable personnel and accessibility to sophisticated equipment, laboratory and radiologic facilities, operating rooms, and intensive care units. The personal commitment of hospital trustees, administrators, physicians, nurses, and other health care professionals also was imperative because the responsibility for providing optimal hospital resources for the care of the seriously injured patient rests with these individuals.