Building a Trauma Center: Structure, Operations, and Performance Improvement: Part 1

As a wise person once said, outcome follow structure and structure controls processes. When you are designing a system to provide complex care any time of the day or night, with the possibility of inexperienced clinicians, a strong internal cognitive and organizational structure are essential. Trauma centers lead the medical world in creating these structures to keep care “between the lines” no matter who showed up at your bedside.

To design a functioning trauma system, you need to include all facets: EMS, ED, OR, ICU, and acute care. In addition you need a well-functioning outpatient clinic component and an injury prevention and outreach program. No Level I trauma center survives without transfers from other trauma centers and non-trauma centers (non-designated hospitals), thus a strong relationship with referring hospitals is essential. This can be difficult when, as you improve, your tolerance for substandard care in the periphery decreases, but you need to subvert your ego and play nice.

 Structure

What is a Trauma Center?

A trauma center is a hospital devoted to trauma care. At its most basic, it includes a trauma service where seriously injured trauma patients are cared for, guidelines and protocols, and an administrative structure. When one of these components is substandard, it will be nearly impossible for the care to be consistent and high quality. I believe a trauma center without guidelines is rudderless. As Brent James says, a guideline is merely a tool to measure variation, if you don’t have any such tool, then your care is random and variable, depending on the whims of whatever practitioner is in charge. An analogy for this is that you have a great chili recipe, and even though you’ve made it hundreds of times, when you don’t use the recipe, its just doesn’t come out right and is different every time.

A trauma center is not a place or a location, it is, in essence, a group of professionals devoted to providing optimal care to the injured patient who is also devoted to examining the care they provide and constantly improving it. There are different types of trauma centers: Level I, Level II, Level III, and in some states Level IV. What holds all of these trauma center levels together is that they all want to provide good care and they all are constantly looking at improving the care they deliver.

I am often asked if I enjoy being an emergency room doctor. I smile and say that I’m surgeon who spends time in the emergency room. Some of my best friends are emergency room doctors but a trauma center does not revolve around the emergency room. The trauma center revolves around the people and processes that are put in place to ensure that injuries are identified quickly, and treated quickly. Trauma centers also have a higher bar with regards to the care that they provide. The community expects them to provide organized efficient care and to realize when the patient has exceeded their capabilities and to rapidly transfer that patient to a center that can give the patient what he or she needs.

Does your community need a Trauma Center?

This is a ongoing area of controversy in the US and abroad. Unfortunately the desire to create a trauma center usually depends much more on economics than on patient need. Many cities were more than happy to let one University hospital admit 5,000 trauma patients a year with little or no help from perfectly capable surrounding hospitals, until reimbursement and payor mix change. At that point, suddenly these hospital have an interest in trauma care. Regardless of the reason, many of these new players do a good job with injured patients, often because they hire accomplished trauma directors and program managers from established centers. What will happen when reimbursement changes in these centers is anyone’s guess.

The usual calculation (only moderately scientific) is that there are 1,000 critically injured trauma patients per million of population. This is not always true due to variations in geography, the willingness of certain populations for high risk behaviors, and such. In my own center, though we only cover approximately 600,000 lives, we see between 1,800 and 2,000 total patients. But the calculation works relatively well for us since we see about 500 ISS>15 patients per year (note).

It is generally accepted that a Level I trauma center should see at least 1,200 admissions/year with at least 250 patients with an ISS>15. This does not mean that a center seeing less patients cannot provide great care, it is merely a framework.

Trauma centers require a great deal of commitment. First of all for the general surgeon who specializes in trauma, most of the patients do not require his operating room skills. This often turns many surgeons away from trauma because they do not wish to practice in a non-operative specialty. However in my case over the 25 years of my career, while I wish I could’ve been in the operating room or the times I do get to the operating room I am usually doing what I call “pure life-saving”. While I certainly do not want a surgeon you only gets their ego gratification in the operating room to go into trauma I do want students and physicians interested in caring for the injured to understand that taking care of the trauma patient involves working in many different parts of the hospital, and working with many many clinicians of the demonstrators to carry out your job well. I say all this to exemplify that devoting your institution to becoming a trauma center is a difficult decision. Many centers become trauma centers for a short period of time and then give up and many centers stay in the trauma business long after the enthusiasm for providing care in the injured has waned. It is very difficult to run a trauma center when only administration wants it to happen, and it is very difficult to provide optimal care when only the physicians want to provide care to the injured. Thus the decision on whether your community can support a trauma center depends on not only the population but the attitude of your hospital toward an endeavor that may cause financial losses and which can be extremely frustrating. But for those centers that devote themselves to providing optimal care to the injured, I believe the vast majority find it to be personally rewarding and beneficial to their community.

The American College of surgeons provides consultation service to hospitals that are considering becoming trauma centers. I would greatly encourage these centers to partake of this service in that it can prevent frustration down the road when an actual site visit occurs, and it will allow everyone to know what the true expectations are of a trauma center so that they can devote the necessary resources, or cut bait and run. The United States is lucky in that every metropolitan area is covered by trauma centers yet many rural areas are poorly covered. It is a paradox in that while these rural areas may require optimal trauma care the most, due to long transport times and the dearth of qualified providers, they are the most sparsely served because trauma volumes made below and it is difficult to recruit the necessary clinicians to provide great trauma care. With the abundance of aeromedical resources regional trauma centers are the norm in rural areas. My own trauma center covers an area of approximately 22,000 mi.² and a population of between 600 and 800,000 people depending on how you calculate the census. This provides us with yearly admissions of approximately 1800 patients with between 250 and 350 severely injured patients every year. My service admits 1000 patients a year of which 70% spend time some time in the intensive care unit. This provides a solid number of clinical cases for our clinicians to maintain competence in all facets of trauma care.

 

Your own community must look at the capabilities of its hospital facilities, its population, its EMS resources, and its regional resources, before making the critical decision to support the development of a trauma center.

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