The Trauma in America’s Trauma Care

Thousands were killed Sept. 11, 2001 in New
York City—that we all know. What isn’t widely known is that many, many
more—over 7,000—were injured, some gravely. There were so many wounded
that treating them stretched the resources of the region’s trauma care
capabilities. Because New York City was unable to care for so many
injured, victims had to be transported to 108 hospitals throughout New
York, New Jersey, and Connecticut.

When an ammonium nitrate bomb with a blast
equivalent to two tons of TNT was detonated April 19, 1995 in front of
the Alfred P. Murrah Federal Building in downtown Oklahoma City, a
local trauma center proved critical. Eighty-three survivors had to be
triaged to local hospitals. The most seriously injured were rushed to
Oklahoma University Medical Center’s (OUMC) Level I trauma center. Six
died, but that number would have been much higher had the trauma center
not been only a few miles away.

Oklahoma’s only trauma center now faces
permanent closure. At present, it’s on life support. The problem: High
operating losses. Without a major infusion of state funds, it will shut
its doors in June. But while OUMC is hoping for a bailout from the
state, the state itself is facing a budget crisis. Oklahoma’s
Commissioner of Health, James Crutcher, said Feb. 15 there are “serious
obstacles” that must be resolved if the trauma center is to stay open.
The governor wants a substantial new tax on cigarettes to fund it.

“Since all other regional trauma centers in
Oklahoma have already shut down,” the closure of Oklahoma’s only Level
1 trauma center would “require the most seriously injured…to be taken
to Texas or Kansas, and some will not survive the long transport. In
the event of a major terrorist attack, many people with serious
injuries who would otherwise survive will die,” states the report, U.S.
Trauma Center Crisis: Lost in the Scramble for Terror Resources,
published Feb. 11 by the National Foundation for Trauma Care (NFTC).

Adequate national trauma care has never been
more important to the United States than it is in the aftermath of
9/11. Trauma centers are crucial to saving lives in the “golden hour”
after a traumatic injury. But across the country a funding crisis is
jeopardizing the entire network of trauma centers that would be the
first line of response in the event of a catastrophic terrorist attack.

Futhermore, there’s been no integration of
trauma care with national terrorism preparedness efforts according to
the report, U.S. Trauma Center Economic Status, commissioned by the
Department of Health and Human Services’ (HHS) Health Resources and
Services Administration (HRSA), the federal agency responsible for
administering state grants to develop and maintain statewide trauma
programs. Not only does this study highlight the deteriorating
financial condition of the nation’s trauma system and the imminent
closures of trauma centers that will likely occur as a consequence, but
it determined that “to date, federal offices addressing homeland
security issues have little contact with the field of trauma care, and
attempts to connect with them have been ignored…Trauma care is not even
on the agenda for the nation’s response to terror, much less a
priority.”

Dangerous unpreparedness

Prepared by the National Foundation for
Trauma Care at the behest of the HRSA’s Office of Special Programs’
Division of Health Care Emergency Preparedness, the report has been
embargoed from public disclosure since it was completed in Nov., 2002.
The NFTC made it available to Homeland Security Today.

“The last thing they want is for the public
to know that we’re not prepared,” said Connie Potter, executive
director of the Foundation’s Trauma Resource Network and former
administrator of the State of Oregon’s trauma resource planning. “Since
it is obvious HRSA isn’t going to release the report, we decided we
would make it public.”

Potter said “HRSA agrees they have no rights
to the information” collected by her organization used to support the
report’s conclusions.

HRSA officials were unable to be reached for comment.

Saint Vincent Catholic Medical Centers’ Mark
Ackermann is a board director of the NFTC and is familiar with the
study. “I guess it would be most appropriate to say I can only hope
that [the HRSA is] carefully studying it to make sure that they get
appropriate fixes in place before they even acknowledge that they even
have the report and are ready to release it…It’s relatively damning …”

“At this point in time, there is very little
being done that we’ve been able to find out on Capitol Hill to address
the issue of the numbers of trauma centers diminishing…If you look at
the money in the federal budget for trauma centers, it’s so minute it’s
hardly able to even be found,” said Ackermann. “States are working hard
to try to assist, but their resources are minimal. Hospitals are losing
enormous amounts of money…because the health care system in our country
is broken…there’s not enough reimbursement for all of this, so one of
the first things that goes is what some people perceive are the extras,
and those are trauma centers.”

Nevertheless, “we have to tie the trauma
system to terrorism preparedness—trauma systems are, and must be,
considered first responders,” Potter argues. Yet, Potter’s group said
in its new report on the crisis that “no funding for [trauma care]
specific to treating serious injuries resulting from terrorist attacks
has been forthcoming…Although trauma is integrally involved with
virtually every terrorist response, the relationship between
bioterrorism resources and state trauma funding has not materialized.
Of 50 states, only four report any amount of terrorism funding directly
to trauma centers or systems. The amounts reported are mostly meager.”

Trauma centers are the first line of injury
care in the event of a catastrophic terrorist attack. They are
specifically designed for the most critical of human injuries. A Level
1 trauma center is required to have up to 16 specialists, such as
neurosurgeons, spinal surgeons and orthopedic surgeons, on call or on
duty at all times. If it doesn’t or can’t, it has to close.

Thirty trauma centers have closed since 2001,
and many others are considering closure or are restricting access to
the seriously injured. They are located in cities where terrorists are
most likely to strike. As of Feb. 9, five Level I trauma centers have
permanently closed and five have temporarily shut down. Seven Level II
units have been permanently closed and four are temporarily closed. The
doors to three Level III centers have been permanently shut.

Meanwhile, two Level I centers and two Level
II units have been downgraded to Level III, while one Level I and two
Level II units are facing closure.

“We are losing critical infrastructure in the
very places we need them most!” declares the NFTC Feb. report, U.S.
Trauma Center Crisis: Lost in the Scramble for Terror Resources.
Without corrective action, the current rate of closures among the
nation’s 600 regional trauma centers will increase, with 10 percent to
20 percent closing within three years.

Economic squeeze

Sixty-one regional trauma centers closed
between 1988 and 1991 due to economic factors. Congress’ investigative
arm, the General Accounting Office (GAO), had recognized the problem as
far back as May 1991 when it reported to the Senate Subcommittee on
Health for Families and the Uninsured that “many hospitals that make up
trauma systems are struggling to keep their centers open. Nationwide,
about 60 trauma centers have closed in the past five years, leaving
about 370 designated to provide trauma care. Major urban areas are
particularly hard hit.”

Although trauma center closures during this
period included some that were not an essential part of the national
“trauma safety net,” what was once surplus capacity in threatened
regions no longer exists. Trauma system progress was slow during the
90’s, but the decade proved relatively stable with only one trauma
center closure. Since 2000, however, this situation has changed
dramatically for the worse. To date, only eight states have provided
any significant trauma center support.

In Tennessee, hospital officials complained
openly in February that five of the state’s six major trauma centers
still haven’t received any of the $8.9 million in federal money awarded
last year for hospitals. The Tennessee Department of Health spent more
than half of a $2.4 million grant from the HRSA in 2002 on
administrative costs, the Chattanooga Times Free Press reported. That
included a $700,000 contract to a Maryland-based consultant to develop
a plan on how to spend future grants. Tennessee has already seen the
closure of the Level 1 trauma unit at the University of Tennessee Bowld
Hospital.

“The escalating severity of trauma center
economic challenges has seriously jeopardizedorganized trauma care
across the nation…Thirty-one states (61 percent) report underserved
areas with too few trauma centers,” the NFTC study found. A full one
quarter of California’s residents, for example, are without nearby
trauma injury services.

According to the Centers for Disease Control
and Prevention (CDC), “despite evidence that trauma care systems save
lives, existing systems serve only one-fourth of the U.S. population.
As many as 35 percent of trauma patients who die do so because optimal
acute care is not available.”

An HRSA report that was made public, 2002
National Assessment of State Trauma System Development, Emergency
Medical Services Resources, and Disaster Readiness for Mass Casualty
Events, notes “economic support for trauma systems appears to be a
major concern among all States. The threat of inadequate funding
manifests itself in the consistent uneasiness regarding the recruitment
and continued retention of trauma care providers.”

In the meantime, a CDC-funded program, the
National Study on Costs and Outcomes of Trauma Care (NSCOT), is
underway to address the Centers’ programmatic interest in comparing the
costs and outcomes of care provided in trauma centers and non-trauma
center hospitals. This investigation “represents a critical first step
in determining the cost-effectiveness and efficiency of an overall
systems approach to trauma care,” according to a study fact paper.

While HHS is apparently waiting on the
findings of the efficacy of a “systems approach” to trauma care, public
health experts who worry about terrorism preparedness say the nation’s
network for responding to and treating trauma injuries has decayed so
much that it’s comparable to the national trauma system of 25 years
ago—and growing worse. The economics of keeping trauma centers
open—rising liability insurance premiums for trauma unit physicians and
the costs associated with the legal requirement to provide care to
uninsured patients—is largely faulted.

Trauma centers collectively experience a $1
billion annual loss, and with increasing costs, this problem will
worsen over time. Key factors in this crisis include the fact that a
disproportionate—and growing—number of trauma patients lack the means
to pay or aren’t covered by any kind of insurance. Medicare often won’t
cover operations, and state Medicaid programs reimburse hospitals very
slowly.

The principal reasons for trauma center
closings were recognized more than a decade ago. A 1990 national survey
of 66 closed trauma centers across 14 states indicated that inadequate
financing and physician participation were commonplace. The findings
supported the work of other investigators and demonstrated that
uncompensated care, inadequate reimbursement, high operating costs, and
lack of physician support all adversely affect trauma care in both
urban and suburban settings.

In May, 1991, the GAO reported that closures
up to that time “were due to financial losses sustained from treating
the uninsured and patients covered

by Medicaid and other government-assisted
programs.” The GAO noted that many centers “may be unable to remain
open without some way to stem financial losses from uninsured,
Medicaid, and other government-assisted program patients.”

“Although hospitals expected that operating a
trauma center would be expensive, most have found the financial strain
to be greater than anticipated,” the GAO stated, emphasizing “many have
concluded that the financial losses cannot be borne. Of the 36 trauma
centers GAO reviewed, 15 have closed—12 primarily because of financial
losses. Most of the currently operating trauma centers reviewed lost
money. Some hospital officials said they might not be able to keep
their trauma centers open in the face of continuing losses.”

In 1992, the GAO again reported to Congress
that, for “hospital units specializing in the treatment of severe
injury, the impact of providing uncompensated treatment…is believed to
be especially significant.”

“We’re not looking for Band-Aids here. We
need long-term solutions. We need long-term tort reform, and we need to
cap liability. We have to solve these overall problems [if we’re going
to] solve the trauma center problem,” Dr. Michael Daubs of the Nevada
Orthopedic Society, has said publicly.

In 2004, these same “emerging economic
threats are causing a growing number of trauma centers to consider
cutbacks or closure,” says the NFTC. “The outlook is bleak because
trauma centers are faced with declining revenues as a result of managed
care, exploding costs for physician support,and rising numbers of
uninsured patients…the basic problem is not the lack of economic
support, but inadequate institutional infrastructure. There are weak
resources and mechanisms for trauma centers to collaborate on common
problems, trauma data centers are in disarray, and anemic… advocacy has
resulted in an unusual void of federal, state and local support for an
essential public good with a very high media profile. When trauma
centers experience problems, they are largely left to their own devices
for survival.”

Finding solutions

“The solution is a private/public effort in
which individual trauma centers can contribute and participate,”
according to the NFTC. “The federal role should be to fund the research
and development of a national trauma system infrastructure. It should
also support specific functions for which there is a direct national
interest. The nation’s trauma centers can then meet the needs of
America’s communities, and develop an integrated capability to respond
to domestic terrorism.”

The role of trauma care in terrorism
preparedness cannot be overstated. As the embargoed HRSA report
emphasizes, “virtually all terrorist events result in traumatic
injuries, and trauma centers and systems need to be prepared. Trauma
centers need to expand their current disaster plans to respond to any
form of terrorist event. Significant attention is needed to the
contribution trauma/centers can make to support hospital preparedness
for all forms of terror…”

The bottom line, Ackermann says, is “more
people will die [in the event of a large-scale terrorist attack] if
trauma centers are not given the kind of resources they need to stay
open and to prepare for major and catastrophic terrorist events.”

“When a trauma center closes, it closes to
all,” the withheld HRSA report makes clear. “Other hospitals in the
area, without the expertise and resources of a regional trauma center,
must accept seriously injured patients and provide treatment. While
their nursing and medical staffs struggle to do their best, they lack
the necessary skills, training and resources. Some patients will die,
and others will face prolonged and poor recoveries.”

Some already have died. Examples were
provided during debate on a medical malpractice litigation reform bill
early last year. “The crisis is real, the crisis is upon us, and the
crisis is severe,” said Rep. Jim Greenwood, (R-Pa.). “We have the best
health care system in the world, but people will, and have, already
died because they could not get to a trauma center.”

“It’s frightening—we’ve almost reached the
point of no return,” Potter said, adding, “this is not an episodic
problem; this is a pandemic problem and it’s only going to be resolved
at a national level.” The embargoed HRSA report itself states “the
track record and trends facing trauma centers are ominous…these trends
are continuing and will result in a significant portion of the nation’s
trauma centers closing within the next three years without increased
support.”

Despite the HRSA’s mandate to strengthen the
nation’s trauma care system, though, critics complain the amount of
funding obligated for it is a drop in the bucket. In October, HRSA
announced $1.9 million in funding to support and strengthen state
trauma systems through infrastructure development, but this translated
to only about $40,000 per state; “hardly what’s needed,” Potter said.
Funding for 2004 was stalled in Congress last fall and, asa result, a
number of states have put their statewide trauma planning programs on
the back burner, according to Potter and a variety of other authorities.

For their part, state officials expressed
concern that HRSA funding was insufficient for states to meet the
requirements of the 2002 hospital terrorism preparedness program. The
GAO reported Feb. 10 that funds allocated to individual hospitals
ranged from $1,000 to $80,000. “State officials expressed concern that
HRSA funding was insufficient to accomplish the 2002 goals of the
cooperative agreement program,” and that “some reported that HRSA funds
were spread thinly across many hospitals and other health care
entities.” Compounding the problem, the GAO determined that states’
“difficulties in increasing personnel [are] a result of state and local
budget deficits.” State and local officials told federal auditors that
budget deficits have led to hiring freezes and reductions in critical
public health personnel.

Following the 2001 anthrax attacks, Congress
appropriated funds to strengthen state and local bioterrorism
preparedness through the CDC’s Public Health Preparedness and Response
for Bioterrorism Program, and HRSA’s National Bioterrorism Hospital
Preparedness Program. The money was distributed in 2002 to state,
municipal and territorial governments. To strengthen preparedness, the
two programs required participants to complete specific activities
designed to build public health and health care capacities. The 2002
cooperative agreements for both programs expired on August 30, 2003 and
have not been replaced.

In addition, the Homeland Security Act of
2002 directed the HHS Secretary to set goals and priorities in
developing a coordinated strategy, including benchmarks and outcome
measures for evaluating progress for all public health-related
activities to improve state, local and hospital preparedness. The
Department of Homeland Security’s (DHS) Office of Emergency
Preparedness (OEP), previously part of HHS, is responsible for
coordinating the federal government’s emergency medical response to all
types of terrorist attacks and natural disasters. Among the OEP’s
mission is implementation of the Metropolitan Medical Response System
(MMRS) program, which is supposed to provide funding to cities that
upgrade and improve their own planning and preparedness to respond to
mass-casualty events.

But according to the First Mayor’s Report to
the Nation: Tracking Federal Homeland Security Funds Sent to the 50
State Governments, issued in September, “officials in nearly half the
survey cities (48 percent) do not believe their city government or
health department had an adequate opportunity to participate in their
state’s planning process for public health and hospital preparedness
activities to be funded through” DHS’s $1.37 billion Public Health
Emergency Preparedness and Hospital Preparedness program.

The GAO found, though, that “states reported
varying degrees of progress in addressing the priority issues that HRSA
required them to address, such as receipt and distribution of
medications and vaccines, personal protection of health care workers,
quarantine capacity and communications.” Most states reported they had
not identified which hospitals in the state to target for capital
improvements, nor had they assessed the need for terrorism-related
diagnostic and treatment protocols and mechanisms to bring clinicians
up to speed on these protocols.

The GAO found that “components of a hospital
response plan not reported as complete by most states included” a
mechanism to ensure the movement of equipment maintained by hospitals
or emergency medical services systems to the scene of a bioterrorist
event; a system that allows for the delivery of essential goods and
services to patients and hospitals during a terrorist attack; and a
system to ensure access to medically appropriate care to children,
pregnant women, the elderly and those with disabilities in the event of
an attack.

At a May 23, 2003 hearing on proposed 2004
HRSA trauma system funding, the American College of Surgeons (ACS) said
in a prepared statement that “over the past decade, the [HRSA’s]
Trauma-EMS Program has distributed almost $25 million in funds to all
50 states and five territories. But today, even with this influx of
federal monies, the United States’ trauma systems remain incomplete
and, unfortunately, only one fourth of the U.S. population lives in an
area served by a trauma care system.”

The Trauma-EMS Program was part of the Trauma
Care Systems Planning and Development Act of 1990, which was enacted in
response to a 1986 GAO report which found severely injured individuals
in a majority of both urban and rural areas of the U.S. sampled were
not receiving the benefit of trauma systems, despite considerable
evidence that trauma systems improve survival rates. The Act was
designed to provide states with federal funds to develop, and monitor
trauma care systems. Congress authorized $60 million for fiscal year
1991, and “such sums as necessary” in fiscal years 1992 and 1993—but
the $60 million was never actually appropriated. In fiscal year 1992,
Congress appropriated only $4.9 million to implement the provisions of
the act. Through fiscal year 1995, a total of $18.8 million had been
appropriated. Of this $18.8 million, though, only $12.2 million was
awarded, and it was divvied up between 42 states over 3 grant years.

According to the NFTC and trauma care
experts, ensuring an adequate nationwide trauma response system will
require additional trauma center capacity to accommodate large numbers
of injuries, support for critical access trauma centers in unserved
regions, planning activities to assure preparedness of all available
resources and constant training of personnel.

The ACS said “the latest findings indicate
that almost half the states still lack a comprehensive trauma care
system. With the events of September 11, 2001 still fresh in our minds,
and with our nation’s renewed focus on enhancing disaster preparedness,
it is critical that the federal government increase its commitment to
strengthening programs governing trauma care system planning and
development. Trauma systems are a crucial component of homeland
security. If a terrorist attack should occur in the U.S., the presence
of a coordinated trauma system to immediately respond to the injured
will save countless lives.”

“One of the most important elements of an
effective [mass patient] response plan is the development of hospital
surge capacity,” explained Jerome M. Hauer, former HHS acting Assistant
Secretary for Public Health Emergency Preparedness. Hauer is concerned
that hospitals have not done enough to prepare to handle mass
casualties.

And they’re not getting much assistance from
state governments, either. “No state” had developed a
federally-required “plan for the hospitals in the state to respond to
an epidemic involving at least 500 patients,” explained Janet Heinrich,
director of GAO Health Care-Public Health Issues, in testimony before
the House Committee on Government Reform in early February “No state is
fully prepared to respond to a major public health threat…Furthermore,
no state reported having protocols in place for augmenting personnel in
response to large influxes of patients, and few states reported having
plans for sharing clinical personnel among hospitals. In addition, few
states reported having the capacity to rapidly establish clinics
to…provide treatment to large numbers of patients.”

Heinrich further told lawmakers that
“regional planning between states is lacking, and many states lack
surge capacity—the capacity to evaluate, diagnose and treat the large
numbers of patients that would be present during a public health
emergency.”

Grim prognosis

In the Washington, DC region, hospitals are
strained on any given day without having to worry about an influx of
terrorism victims. Without adding beds and personnel, Capital area
facilities will be rapidly overwhelmed if thousands or even hundreds
suddenly need medical attention—Washington hospital officials estimate
only 400 beds could be freed during a disaster.

At a homeland security summit convened by
Missouri’s Rep. Ike Skelton (D-Mo.) in Jan., 28-year Army veteran, Col.
(Ret.) Tim Daniel, the state’s homeland security director, said “this
region’s hospitals could not take the load” of a large-scale attack.

Dr. David Ciraulo, chief trauma surgeon for
Erlanger hospital in Chattanooga, Tenn., said his hospital is also
unprepared to handle massive numbers of “walking wounded.”

Dr. Patrick O’Brien, head of homeland
security services at the University of Tennessee Medical Center in
Knoxville, said most hospitals in Tennessee have done nothing to
prepare themselves. “We have thousands of health-care workers who need
training,” he said.

And yet, “there will be other catastrophic
[terrorist] events in our country,” Ackermann said. “If anybody thinks
there won’t, they’re kidding themselves…There are going to be other
mass casualty events in our country, and our trauma centers must be
ready—they are on the forefront; they are where people will go.” HST

Trauma Centers and their levels of care

All trauma centers are licensed hospitals,
designated by a local emergency medical services agency as a trauma
center, and include personnel, services and equipment necessary for the
care of trauma patients. General requirements for all trauma centers
include:

  • A trauma program medical director and a trauma nurse coordinator
  • A basic emergency department (minimum)
  • A multidisciplinary trauma team
  • Specified service capabilities

Trauma Center Designations

Level I Centers—24/7 on-site surgical staff,
dedicated operating rooms and access to laboratory services and
sub-specialties including cardiac surgery, neurosurgery, plastic
surgery, anesthesiology and radiology.

Level II Centers—Not required to have
designated resources on-site 24/7. Surgeons must be promptly available
at all times, but may not always be at the hospital. Level II Centers
are not required to offer constant access to cardiac or pediatric
surgeons.

Level III Centers—Provide quick assessment, stabilization and some
surgical intervention for patients. A general surgeon is required to be
promptly available, but no other surgical specialties are mandated.
Depending on the severity of the patient’s injuries, Level II and III
centers may transfer their patients to a Level I facility.

Reports used in this article

GAO Report, “Trauma Care: Lifesaving System
Threatened by Unreimbursed Costs and Other Factors”
http://161.203.16.4/d20t9/143946.pdf

GAO report, “HHS Bioterrorism Preparedness
Programs: States Reported Progress but Fell Short of Program Goals for
2002” http://www.gao.gov/new.items/d04360r.pdf

GAO report, “Public Health Preparedness:
Response Capacity Improving, but Much Remains to Be Accomplished”
http://www.gao.gov/new.items/d04458t.pdf

GAO report, “Health Care: States Assume
Leadership Role in Providing Emergency Medical Services”
http://161.203.16.4/f0302/131470.pdf

GAO report, “Trauma Care Reimbursement: Poor
Understanding of Losses and Coverage for Undocumented Aliens”
http://161.203.16.4/d35t11/147745.pdf

GAO report, “State Trauma Grants” http://161.203.16.4/paprpdf1/154011.pdf

“A 2002 National Assessment of State Trauma
System Development, Emergency Medical Services Resources, and Disaster
Readiness for Mass Casualty Events” ftp://ftp.hrsa.
gov/hrsa/trauma/nationalassessment.pdf

National Foundation for Trauma Care reports: Contact the Foundation via Web, http://www.traumacare.com/mtcp.html

Centers for Disease Control and Prevention
Web site on trauma care http://www.cdc.gov/ncipc/
fact_book/28_Trauma_Care_Systems.htm

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The Government Technology & Services Coalition's Homeland Security Today (HSToday) is the premier news and information resource for the homeland security community, dedicated to elevating the discussions and insights that can support a safe and secure nation. A non-profit magazine and media platform, HSToday provides readers with the whole story, placing facts and comments in context to inform debate and drive realistic solutions to some of the nation’s most vexing security challenges.

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