Identifying Trauma System Components

Paul M. Maggio

In the United States, injuries are the leading cause of death for ages 1 to 44 and are the fourth leading cause of death for all ages.¹ The magnitude of traumatic injury as a public health problem is enormous. As an epidemic affecting all ages, the cost of caring for injured patients is approximately $260 billion each year and the resulting loss of productive life years is greater than any other single cause.² Yet, the importance of injuries as a public health problem fails to be fully appreciated by the community.

Efforts to develop an organized response to injuries have been made through government initiatives such as the U.S. Department of Health and Human Services (HRSA) and legislation, as well as through organizations such as the American College of Surgeons Committee on Trauma (ACSCOT). Their most recent recommendations have focused on the development of an inclusive system that incorporates all acute care facilities as opposed to a system that focuses solely on designated trauma centers. As a result, guidelines for trauma system development in the United States have evolved from single centers to more coordinated and integrated networks of trauma care delivery, capable of delivering better care inboth urban and rural environments, as well as in the event of mass casualties.

DEVELOPMENT OF TRAUMA SYSTEMS IN THE UNITED STATES

A trauma system is an integrated multidisciplinary organization to care for the injured patient. Ideally, it should provide timely, appropriate, and standardized care for a defined geographic region. In conjunction with a means of monitoring system performance, it must also incorporate a system for process improvement.

The first proposal by ACSCOT to provide formal guidelines for the structure of a trauma system was published in 1976 in the document titled, Optimal Hospital Resources for Care of the Seriously Injured.³ These initial guidelines were institutionally based and resulted in a relatively exclusive system that concentrated largely on the acute care of the injured patient, as well as defining the structure, staffing, and necessary equipment required for development of a trauma center. It has served as the basis for trauma center verification and designation. The ACSCOT guidelines were remarkable in standardizing the provision of health care to the injured patient, and subsequent studies have demonstrated that in contrast to centers without such expertise, designated trauma centers achieve better outcomes.⁴,⁵,⁶,⁷,⁸

The first model for the development of trauma systems to emphasize the importance of an inclusive system was initiated over a decade later by HRSA. Directed by the Trauma Systems Planning and Development Act of 1990, HRSA created the Model Trauma Care System Plan in 1992.⁹ Never officially published by the federal government, it serves as a “living” document that continues to be revised and guides trauma system development in the United States. In contrast to an exclusive system, this model incorporates all acute care facilities and services at a state or regional level in a system designed to care for all injured patients by matching them with the appropriate facilities and available resources.¹⁰ Integrating all facilities into a single state or regional system will limit the number of duplicative services and directs the most severely injured patients to a few high-volume institutions. This design is expected to reduce the overall injury-related mortality through a more efficient and cost-effective process in which the needs of all injured patients can be met by the most appropriate
institutions.¹¹,¹²,¹³ In addition, as an integrated system capable of providing a continuum of services from injury prevention to prehospital care, acute care, and subsequent patient rehabilitation, it is better prepared to address traumatic injury as a public health problem. Traumatic injury is no longer viewed as an “accident,” but in the context of a public health model it is viewed as a disease that can be predicted and prevented. The outcome, therefore, can be improved through a multidisciplinary and coordinated approach that not only improves the delivery of acute and subsequent care but also reduces its incidence and severity.

TRAUMATIC INJURIES AS A PUBLIC HEALTH PROBLEM

Public health is defined as “what we as a society do collectively to assure the conditions in which people can be healthy.”¹⁴ Recognition of traumatic injuries as a public health problem was highlighted by a 1966 publication from the National Academy of Sciences and the National Research Council, Accidental Death and Disability: The Neglected Disease of Modern Society.¹⁵ This document identified trauma as a major public health problem, made specific recommendations to reduce the associated death and disability, and provided the impetus for trauma system development over the next 30 years. Further emphasis of traumatic injuries as a public health problem was spurred by the events of September 11, 2001, and natural disasters such as Hurricane Katrina that devastated the north-central Gulf Coast of the United States in 2005. Shortly after the September 11 attacks, an assessment of state and regional responses to emergency medical events was performed by HRSA and the resulting publication—A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events—found that although trauma system development continued to progress on a local level, funding and personnel were inadequate and communication and coordination on a state and regional level were too limited.¹⁶ Organizations such as the Institute of Medicine (IOM) and American College of Surgeons (ACS) have echoed these findings,¹⁷,¹⁸ and in response, ACSCOT and HRSA have recently provided recommendations for the most comprehensive and inclusive model for trauma systems to date.

COMPONENTS OF AN INCLUSIVE TRAUMA SYSTEM

To fulfill its role in coordinating a multidisciplinary response to prevent injuries and care for the injured patient, a comprehensive and integrated trauma system must seamlessly provide a wide spectrum of care. This care ranges from public education and preventive intervention to prehospital care, triage and transportation, emergency department care, operative intervention, general and intensive care, rehabilitative services, social services, and medical follow-up (see Fig. 1). Importantly, it must perform these functions in both a rural or urban setting and maintain the capability to provide all-hazard care in the event of mass casualties. ACSCOT in its latest version of Resources for the Optimal Care of the Injured Patient 2006 has defined the necessary administrative and clinical components (see Table 1).¹⁹ The administrative components address the requisite leadership to implement a trauma system including cooperative efforts with governmental agencies and the creation of new legislation. The clinical and operational components form the infrastructure for a coordinated, multidisciplinary, and multi-institutional approach to caring for the injured patient. On the basis of a facility’s capabilities and available resources, patients are triaged to receive standardized and evidence-based care that is performed in conjunction with a system of data collection, research, and process improvement.

Injury Prevention

The epidemiology of traumatic injuries provides an opportunity to identify high-risk groups, assess individual risk factors, and develop evidence-based preventive interventions. Injury prevention programs are required for all trauma systems and can be categorized as primary, secondary, or tertiary preventions.¹⁹ Primary injury prevention is the avoidance of the injury itself, for example, restricting the sale of alcohol to minors in order to decrease the incidence of alcohol-related motor vehicle collisions.²⁰ Secondary prevention efforts are intended to limit the severity of injury, such as legislation enforcing the use of seat belts. Tertiary prevention activities are designed to limit the effects of the injury or improve patient outcome after the injury has already occurred. Improving access to definitive care facilities and following evidence-based treatment guidelines are examples of tertiary preventive measures.

Preventive interventions raise the public awareness of traumatic injuries as a public health problem, modify public behavior through legislation and education, and familiarize the public with the function and capabilities of a trauma system. Since one third to one half of trauma deaths occur in the field before receiving treatment, investing in injury prevention programs that decrease the incidence and severity of injuries may improve public health and reduce health care costs more so than focusing primarily on postinjury care.⁷,²¹

Patient Triage

Patient triage depends on a reliable communication network that matches a patient’s needs with the most appropriate available resources. The challenge of field triage, faced by emergency medical services (EMS), is timely
transfer to an appropriate definitive center despite limited diagnostic capabilities. Decreased duration of prehospital care is vital in optimizing patient outcomes.²²,²³,²⁴,²⁵,²⁶ To efficiently evaluate a patient’s needs, a number of triage scoring systems based on physiologic and anatomic data as well as the mechanism of injury have been developed. Examples include the Revised Trauma Score (RTS), Prehospital index (PHI), circulation, respiration, abdominal, thoracic, motor, and speech (CRAMS) scale, and the ACS Field Triage Scheme. These scoring systems have all been shown to correlate with outcome, but no single system has been proved to be significantly better than the others.²⁷,²⁸,²⁹ Regardless of the scoring system used, it must include a process of monitoring and evaluation of system performance coupled with a plan for process improvement. Monitored parameters must include the number of undertriaged and overtriaged patients. Undertriaging patients to lower level acute care facilities when they actually would be better served in a trauma center may adversely affect patient outcome, whereas overtriaging patients to trauma centers when they would be managed equally as well in a nontertiary care setting may overburden the system and impair access to care. Therefore, measures to improve the performance of a triage system should be guided by the goals of lowering undertriage and overtriage rates in order to more closely match a patient’s needs with the appropriate resources. A field triage system must therefore be standardized, easy to use, reproducible, and its assessment score should correlate with patient outcome.

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