The Blue Cottage Blog

Trauma Systems: A Template for Optimal Patient Care

by on November 3, 2015

Imagine if you will, it is Saturday evening at about 7:00 pm when the trauma radio pipes up with an announcement:

“Class 1 trauma: 56 year old male involved in a roll over motor vehicle crash, ejected from the vehicle, has a left leg deformity,” says the dispatcher. “Blood pressure is 86/48, heart rate 128. Patient was unconscious at the scene and intubated. ETA via air ambulance is 10 minutes.”

The trauma team mobilizes and prepares for the patient’s arrival. Simultaneous notification for all players on the trauma team sets activities in motion: the OR preps a room, anesthesia is on standby, Radiology prepares to hold a CT scanner, nurses and physicians gather in the emergency room (ER) trauma bay, and the ICU prepares a bed.

Once the patient arrives, the group moves like a well-oiled machine. The ER physician is in charge of the airway, the trauma physician is the “quarterback” directing all patient care, radiology is present to take chest and pelvis x-rays, respiratory therapy prepares the ventilator, a nurse scribes information as pre-hospital report is given and patient assessment begins, another nurse inserts IV’s and hangs blood.

Trauma is the number one cause of death for Americans between 1 and 46 years old. Each year, trauma accounts for 41 million emergency department visits and 2.3 million hospital admissions.

Most people do not realize what it means to be a verified trauma center. It actually conveys quite a bit about a hospitals’ capabilities and overall organization. Trauma centers are verified by the American College of Surgeons as a Level I, II, III or IV center. Some states have their own designation standards and do not use the American College of Surgeons (ACS) but criteria are similar or, at times, more stringent. Developing a trauma care “system” is actually the focus of trauma hospital designation and studies show that state trauma systems reduce mortality. A network of definitive care facilities is able to provide the spectrum of care across the trauma continuum based on severity of injury and available resources.

Trauma Tiers Defined

  • Level I: A regional resource that provides the highest level of trauma care, often a tertiary care facility. Has personnel at the ready 24 hours per day and has a major responsibility to provide leadership in education, research and trauma system planning. All Level I’s must have prevention programs to address community issues and provide education. Additionally, they must have a volume of 1200 patients per year or have more than 240 high acuity patients per year (defined using an injury severity scoring system). Basic science research is expected.
  • Level II: Clinically approaching or comparable to a Level I hospital except for complex, specialized injuries such as replantation. In absence of a Level I facility, a Level II should provide education and trauma system leadership. Immediate availability of board-certified emergency physicians, general surgeons, anesthesiologists, neurosurgeons and orthopedic surgeons is required. Other specialists are also required within defined timeframes.
  • Level III: Provides prompt assessment, resuscitation, emergency operations and stabilization for the injured trauma patient. Participation in a regional trauma system is essential with transfer agreements and standard treatment protocols. A Level III serves communities that do not have access to a Level I or II and will assume education and system leadership in remote areas as needed. A dedicated intensive care unit team with surgical direction is required.
  • Level IV: Often in remote areas with a physician or mid-level provider caring for trauma patients. Provides advanced trauma life support prior to transfer to higher level of care if needed. Must have a relationship with nearest Level I, II or III trauma center.

An inclusive trauma system requires all verified trauma centers levels I-IV to have treatment and transfer protocols, trauma patient registry, data reporting, and a robust performance improvement process. Driven by the patient’s injuries and available hospital resources, the goal of the trauma system network is to expedite the patient to the highest level of definitive care as soon as possible.

A hallmark of verified trauma centers is their rigorous approach to performance improvement and patient safety (PIPS). Focus includes the entire spectrum of care from pre-hospital to the emergency department to inpatient to rehabilitation. The multidisciplinary trauma system operations committee reviews operational events, analyzes data and proposes corrective actions in a variety of methods including:

  • Guideline, protocol or pathway development or revision
  • Targeted education
  • Additional or enhanced resources
  • Peer review presentation
  • External review or consultation
  • On-going professional practice evaluation

Additionally, verified trauma centers upload data to the National Trauma Databank. This aggregate information forms benchmarks, data quality reports and research data sets.

Very stringent criteria must be met to attain and maintain verification. Trauma hospital site reviews are performed every three years in order to ensure all standards are met consistently. Criteria are numerous and requirements differ based on trauma center designations I-IV. Click on the graphic to the left for a detailed snapshot of criteria and expectations.

There are many departments that perform performance improvement (PI) today, but much of that work is compartmentalized, and the breadth and depth of PI can vary. The goal of this important and valuable work is to affect care not only locally but also across the hospital. For example, similar drug packaging that triggers a medication error on a unit results in the hospital taking action to modify pharmacy packaging throughout the system.

Blue Cottage models PI work in our user group discussions for transition planning. We strive to have the multidisciplinary team in the room, ask the 5 why’s to drill down to root causes, gather data to further explain the issues and discuss possible solutions to challenging situations with all members involved.

Rigorous standards, infrastructure requirements and emphasis on data reporting and continuous performance improvement provide the underpinnings of a verified trauma center. Trauma system organization is a template to which other service lines should aspire. Healthcare is headed in the right direction with a focus on pay for performance and monitoring, reporting, and comparing outcomes such as with the National Surgical Quality Improvement Program (NSQIP). Our journey towards optimal systems of care is just beginning as we turn our attention to Accountable Care Organizations. Coordinated efforts between hospitals and prehospital providers provide a true systems approach thus delivering optimal care for the injured patient. The goal is to affect patient care across a region or state and ensure a patient gets to the right place in the right amount of time with the right resources.

Sources:

1Staff of the American College of Surgeons (ACS) Committee on Trauma. “Resources for Optimal Care of the Injured Patient 2014,” FACS.org. Web 3 November 2015. <https://www.facs.org/~/media/files/quality%20programs/trauma/vrc%20resources/resources%20for%20optimal%20care%202014%20v11.ashx>

2United States Centers for Disease Control and Prevention. “Trauma Statistics,” nationaltraumainstitute.org. Web 3 November 2015. <http://www.nationaltraumainstitute.org/home/trauma_statistics.html>

3National Trauma Databank. FACS.org. Web 3 November 2015. <https://www.facs.org/quality%20programs/trauma/ntdb>

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