6
Trauma Care

The 1966 landmark report Accidental Death and Disability: The Neglected Disease of Modern Society was a clarion call to launch what it termed a "frontal attack" on the care of the injured. At the time, the problem of injury in the United States was met with public apathy, a dearth of 9-1-1 systems, and inadequate provision of care (NRC, 1966). Since then, much progress has been made in developing systems of care that strive to reduce injury-related morbidity and mortality. Trauma care systems deliver a continuum of prehospital, acute care, and rehabilitation services. Yet, despite their public health mission, only a handful of states have put into place comprehensive regional systems of trauma care, although some of the system elements are present in many states and communities (West et al., 1988; Bazzoli et al., 1995). Trauma care is integral to the injury field because it is critical to lessening the consequences of injury.

The purposes of this chapter are to describe trauma care systems, their organization, roles, and patient outcomes; to explore what is known about their costs and cost-effectiveness; to delve into the cardinal problem of financing the high cost of infrastructure and patient care, a problem that has been solved by some states through motor vehicle fees and other creative sources of financing; and to explore the impact of managed care on trauma care systems. The committee decided to focus on these issues rather than explore the fundamental issues related to trauma care and the rehabilitation sciences, since several other reports have discussed specific priorities for research in trauma care and rehabilitation (e.g., NCIPC [1993;]; IOM [1991, 1997a]; NIH [1994]).



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Reducing the Burden of Injury: Advancing Prevention and Treatment 6 Trauma Care The 1966 landmark report Accidental Death and Disability: The Neglected Disease of Modern Society was a clarion call to launch what it termed a "frontal attack" on the care of the injured. At the time, the problem of injury in the United States was met with public apathy, a dearth of 9-1-1 systems, and inadequate provision of care (NRC, 1966). Since then, much progress has been made in developing systems of care that strive to reduce injury-related morbidity and mortality. Trauma care systems deliver a continuum of prehospital, acute care, and rehabilitation services. Yet, despite their public health mission, only a handful of states have put into place comprehensive regional systems of trauma care, although some of the system elements are present in many states and communities (West et al., 1988; Bazzoli et al., 1995). Trauma care is integral to the injury field because it is critical to lessening the consequences of injury. The purposes of this chapter are to describe trauma care systems, their organization, roles, and patient outcomes; to explore what is known about their costs and cost-effectiveness; to delve into the cardinal problem of financing the high cost of infrastructure and patient care, a problem that has been solved by some states through motor vehicle fees and other creative sources of financing; and to explore the impact of managed care on trauma care systems. The committee decided to focus on these issues rather than explore the fundamental issues related to trauma care and the rehabilitation sciences, since several other reports have discussed specific priorities for research in trauma care and rehabilitation (e.g., NCIPC [1993;]; IOM [1991, 1997a]; NIH [1994]).

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Reducing the Burden of Injury: Advancing Prevention and Treatment OVERVIEW OF TRAUMA CARE SYSTEMS A trauma care system is an organized and coordinated effort in a defined geographic area to deliver the full spectrum of care to an injured patient, from the time of the injury through transport to an acute care facility and to rehabilitative care (Eastman et al., 1991; Mendeloff and Cayten, 1991). A trauma care system consists of three major providers—prehospital, acute care, and rehabilitation—that, when closely integrated, ensure a continuum of care. For general descriptions of prehospital, acute, and rehabilitative care, see Box 6.1. This chapter concentrates on prehospital and acute care rather than rehabilitation because the latter was the subject of two recent Institute of Medicine (IOM) reports (IOM, 1991, 1997a). In a trauma system, the integration of prehospital, acute care, and rehabilitation providers is administered by a public agency whose cardinal roles are to provide leadership, coordinate service delivery, establish minimum standards of care, designate trauma centers (offering 24-hour specialized treatment for the most severely injured patients), and ensure system evaluation and refinement. Trauma care systems are best endowed with the following major clinical or operational components: medical direction, prevention, communication, training, triage, prehospital care, transportation, hospital care, public education, rehabilitation, and medical evaluation (ACEP, 1992; HRSA, 1992; ACS, 1993). How these components are configured, organized, and emphasized differs according to state, regional, and local circumstances, as there are many examples of trauma systems throughout the United States. An overarching goal of a trauma care system is to match the severity of the injury to the most appropriate and cost-effective level of care in a geographic region (ACEP, 1992; HRSA, 1992; ACS, 1993). Patient matching is thought to be accomplished best by an inclusive trauma care system (i.e., one that harnesses the resources of all hospitals and trauma care providers in a community or region to meet the needs of all injured patients, the majority of whom [85–90 percent] are not severely injured; ACS [1993]). Most existing trauma systems are "exclusive" in orientation insofar as they focus mostly on the major trauma patient. Exclusive systems do not include all area hospitals, only prehospital providers and trauma centers to which the major trauma patient is triaged. Trauma centers are hospitals that are specially designed to care for the most critically injured patients. There are four levels of trauma center designation (Box 6.2), the pinnacle of which is the Level I center. Inclusive trauma care systems incorporate all hospitals and acute care facilities in a region to deliver quality care for all injured patients, regardless of severity. Inclusive trauma care systems marshal communitywide resources, broaden the number of stakeholders, enhance surveillance capacity, and seek to avert the overburdening of trauma centers with non-critically injured patients for whom expensive trauma center care is unnecessary. An inclusive philosophy of trauma care was espoused by federal legislation, the Trauma Care Systems Planning and Development Act of 1990 (P.L. 101-590),

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Reducing the Burden of Injury: Advancing Prevention and Treatment which until 1995 encouraged the development of, and provided funding for, inclusive systems (see later discussion of financing). The effectiveness of an inclusive system has yet to be empirically evaluated (NCIPC, 1993). BOX 6.1 The Continuum of Care Prehospital Emergency Medical Services (EMS) Prehospital care is the gateway to the trauma care system and a major determinant of patient outcome (Jacobs et al., 1984; Rutledge et al., 1993; Regel et al., 1997). The goals of prehospital care are prompt arrival at the scene, assessment of patients' needs through medically approved protocols for triage (the classification of injury severity and the selection of a hospital destination that matches patients with appropriate clinical resources); preliminary resuscitation and treatment; and rapid transport to the nearest, most appropriate acute care facility (ACS, 1993; Jacobs and Jacobs, 1993). Access to prehospital care is provided almost universally throughout the United States by a telephone call to 9-1-1 (NHTSA, 1997a). There are four levels of EMS providers: (1) first responder, (2) emergency medical technician (EMT)-Basic, (3) EMT-Intermediate, and (4) EMT-Paramedic. The paramedic has substantially more training than the others and is the provider of most advanced life support given outside the hospital. Acute Care Hospitals and primary care providers diagnose and treat the majority of injured patients, but the cornerstone of the trauma care system is the trauma center. Trauma centers are highly sophisticated facilities geared to the most gravely injured. Four levels of trauma center, each with detailed qualifying criteria, have been established and revised by the American College of Surgeons (ACS, 1993). (See Box 6.2 for a description of Level I–IV trauma centers). Many states with the legal authority to designate trauma centers use the ACS's criteria for designation. Hospitals seeking designation in states where such formal authority is lacking often rely on verification by the ACS that they have met its criteria. Rehabilitation Rehabilitation forms the final, and generally the longest, phase of treatment in a trauma care system. The goals of rehabilitation are to improve physical and mental health, reduce disability, and enhance personal autonomy and productivity. Rehabilitation is defined as the process by which physical, sensory, or mental capacities are restored or developed. It is a process that is accomplished through functional improvements in the patient, as well as through changes in the physical and social environment (IOM, 1997a). Rehabilitation is offered on an inpatient or outpatient basis in a designated hospital unit, a freestanding rehabilitation hospital, or in a clinic. In a model trauma care system, rehabilitation begins at the earliest stage possible after admission to an acute care hospital (HRSA, 1992; NCIPC, 1993).

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Reducing the Burden of Injury: Advancing Prevention and Treatment BOX 6.2 Levels of Trauma Centers Trauma centers are acute care facilities that are specially designed to care for the most critically injured patients. There are four types—or levels—of trauma centers, the qualifying criteria for which were established by the American College of Surgeons (ACS, 1993): Level I—A facility that meets criteria for a Level I trauma center has the highest degree of sophistication in treating the most severely injured patients. A Level I trauma center is a regional tertiary care facility required to have immediate availability of specialized surgeons, anesthesiologists, physician specialists, nurses, and resuscitation equipment. It also is required to conduct certain types of prevention and research activities. Level II—A facility that meets a Level II trauma center designation satisfies virtually all of the same clinical and facilities requirements as the Level I center, but is not required to conduct research and certain types of prevention activities. Most cities and suburban areas have Level I and/or II centers. Level III—A facility that meets a Level III trauma center designation is required to have emergency services and the availability of general surgeons, but it is not required to meet the extensive clinical and facilities criteria of a Level I or Level II center. A Level III center typically serves a rural area that does not have a Level I or Level II center. Level IV—A facility that meets a Level IV trauma center designation can be either a hospital or a clinic in a remote area where more sophisticated care is unavailable. It is new classification added by the ACS in 1993 to accommodate patients in the most rural areas by linking them to higher levels of care. The key role of a Level IV center is to resuscitate and stabilize patients and arrange for their transfer to the closest, most appropriate level of trauma center. The plight of rural areas has been a major factor propelling an inclusive philosophy of trauma care systems (Shackford, 1995). Rural emergency medical services have lagged behind their urban counterparts for a host of reasons, including greater transport times, insufficient volume of patients to maintain the skills of providers, and too sparse a population density to sustain local public financing (OTA, 1989; HRSA, 1990). In comparison with urban areas, rural areas experience higher mortality rates for motor vehicle crashes (Baker et al., 1987; Mueller et al., 1988; Flowe et al., 1995) and a higher proportion of deaths at the scene (Rogers et al., 1997b). To incorporate rural acute care facilities into an integrated system of care, the American College of Surgeons (ACS) created a new level of trauma center (Level IV) in 1993 and specified the organizational and clinical criteria needed for a facility to meet this level (Box 6.2). The facility may be a clinic or hospital, with or without a physician available. The purpose of

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Reducing the Burden of Injury: Advancing Prevention and Treatment this classification was to provide optimal care in remote areas with limited resources and, when necessary, to ensure linkage to higher levels of care. Special Populations Children and the elderly are among the special populations that merit emphasis by trauma care systems. Injury is the foremost cause of death among children above 1 year of age and the fifth leading cause of death for the elderly age 65 or over (Chapter 2). Congress authorized the Emergency Medical Services for Children (EMS-C) Program in 1984 to ensure state-of-the-art emergency medical care for injured children and adolescents and to ensure that pediatric services are integrated into trauma systems. The program funds demonstration, implementation, and targeted-issues grants to states and medical schools for the provision of emergency medical services geared to children (IOM, 1993; NIH, 1995). The program grew out of the awareness that children have unique physiological responses to illness and injury and that their treatment requires specific training, equipment, and approaches not ordinarily available in systems designed for adults. The program focuses on the entire continuum of pediatric emergency services, from injury prevention through prehospital, acute care, and rehabilitation services. The committee commends the collaborative efforts of the Maternal and Child Health Bureau (MCHB) and the National Highway Traffic Safety Administration (NHTSA) on the EMS-C Program and urges similar collaborative efforts between MCHB and the National Institute of Child Health and Human Development for investigator-initiated research in the areas of childhood injury epidemiology and prevention. Research has demonstrated that specialized pediatric trauma care is associated with lower rates of pediatric morbidity and mortality compared with rates at adult trauma care centers (or national norms), although adult trauma centers with a pediatric component may be able to achieve outcomes comparable to those of pediatric trauma centers (Pollack et al., 1991; Fortune et al., 1992; Knudson et al., 1992; Nakayama et al., 1992; Cooper et al., 1993; Hall et al., 1993, 1996; Rhodes et al., 1993; Bensard et al., 1994; Hulka et al., 1997). As important, targeted pediatric injury prevention programs have been shown in population-based studies to result in substantial decreases in the incidence of serious childhood injuries (Davidson et al., 1994; Durkin et al., 1996). The National Pediatric Trauma Registry (NPTR), was established in 1985 to study the causes, circumstances, and consequences of injuries to children. Sponsored by the National Institute on Disability and Rehabilitation Research and by the American Pediatric Surgical Association, the NPTR has detailed information on over 50,000 cases of injuries to children. As of October 1996, there were 78 participating centers (pediatric trauma centers or children's hospitals with pediatric trauma units) located in 28 states, Puerto Rico, and Ontario, Canada (NPTR, 1998).

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Reducing the Burden of Injury: Advancing Prevention and Treatment The elderly account for a disproportionate share of injury-related hospitalizations (see Chapter 2). Demographic projections suggest that their share of hospitalizations is likely to grow even more. The need for the full range of treatment efforts targeted to the elderly is especially critical, particularly the need for a seamless transition from prehospital to acute care to high-quality rehabilitation services tailored to their needs (IOM, 1997a). There is some evidence that the elderly with major trauma have an inferior quality of trauma care compared to other age groups. This problem may be the result of two factors: (1) inadequate triage criteria for dispatching an elderly patient to a trauma center, resulting in undertriage (Phillips et al., 1996; Ma, 1997), and (2) a higher risk of complications and death during hospitalization (DeMaria et al., 1987; Champion et al., 1989a; Finelli et al., 1989; Chen et al., 1995; Ma, 1997). More research is needed to identify causes, sequela, and interventions to ensure the highest quality of care for elderly patients. System Management and State or Regional Agencies It has long been recognized that trauma care systems are best managed on a regional basis by virtue of the opportunity to pool and centralize resources and the relative infrequency of major trauma (NRC, 1978; Eastman et al., 1987; Stewart et al., 1995). Major trauma generally accounts for a small percentage (10–12 percent) of overall injury admissions (MacKenzie et al., 1990; National Trauma Data Project, 1996). Injury admissions—of all types and levels of severity—ranged in 1993 from 6.19 to 9.02 admissions per thousand population (National Trauma Data Project, 1996). Consequently, state and regional agencies have come to play essential roles in establishing and coordinating regional and local trauma care systems, many of which receive assistance from the federal government. Federal legislation since the 1970s, such as the Emergency Medical Services Systems Act of 1973 and the Trauma Care Systems Planning and Development Act of 1990, channeled funds to states and regions in order to cultivate the development of systems of care (Table 6.1 contains a chronology of federal trauma system legislation). The 1990 legislation not only authorized funding for development and planning activities (albeit unsustained funding; see later section on financing trauma systems), but also stipulated the creation of a Model Trauma Care System Plan (HRSA, 1992).

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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 6.1 Chronology of Trauma System Legislation 1966 Highway Safety Act authorizes funding for, and requires states to develop, regional EMS systems; also authorizes the Department of Transportation to develop standards for EMS provider training. 1973 Emergency Medical Services Systems Act (P.L. 93-154) authorizes additional federal guidelines and funding for the development of regional EMS systems. 1981 Omnibus Budget Reconciliation Act consolidates EMS funding into state preventive health and health services block grants under the Centers for Disease Control and Prevention (CDC). 1984 Health Services, Preventive Health Services, and Home and Community-Based Services Act (P.L. 98-555) authorizes the Emergency Medical Services for Children Program. 1990 Trauma Care Systems Planning and Development Act (P.L. 101-590) authorizes funding for state and regional trauma systems development. 1995 Trauma Care Systems Planning and Development Act is not reauthorized. The Model Trauma Care System Plan offers a framework for states to build trauma care systems once they have procured legislative authority.1 In broad terms, the plan calls for states to link prehospital, acute care, and rehabilitation providers through leadership, systems development, planning, and evaluation, and through securing financing for system administration and patient care (HRSA, 1992). More specifically, the plan exhorts states to designate trauma centers, establish trauma registries, and ensure, in concert with communities, that triage and transport protocols are in place for the timely assessment and movement of patients to the most suitable acute care facility. Bazzoli and coworkers (1995) found that the most common problem for states was to limit the number of designated trauma centers based on community need. The ACS (1993) underscored the importance of states' limiting the number of designated centers for two primary reasons: (1) trauma teams must treat sufficient numbers of major trauma patients to maintain their expertise, and (2) unnecessary duplication of centers yields excessively high societal health care costs (see also Goldfarb et al. [1996]). The importance of maintaining sufficient patient volume as a determi- 1 By 1992, 41 state and regional agencies had legal authority to coordinate and regulate trauma care systems (Bazzoli et al., 1995). Regional agencies generally refer to counties or groups of counties (Bazzoli et al., 1995) or, occasionally to, private organizations. In the absence of legislation, states have little ability to require the routing of patients to trauma centers (Mendeloff and Cayten, 1991; Bazzoli et al., 1995).

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Reducing the Burden of Injury: Advancing Prevention and Treatment nant of patient survival has been confirmed (Smith et al., 1990; Konvolinka et al., 1995). Still, there is no consensus on the amount of patient volume necessary for optimal performance of a trauma center (Moore, 1995). Personnel and Training More than 30 years ago, the National Research Council (NRC, 1966) spotlighted the paucity of trained emergency personnel at every level of care. The growth in the number of prehospital providers and the increase in their level of training are among the major achievements of the past three decades. The number of prehospital providers is estimated today at about 650,000 nationwide (W.E. Brown, National Registry of Emergency Medical Technicians, personal communication, 1998). Accompanying this growth has been the creation and standardization of the prehospital curriculum. Since the enactment of the 1966 Highway Safety Act, NHTSA has spearheaded the development of standardized curricula for multiple types of prehospital personnel (U.S. DOT, 1996b). In a series of evaluations conducted from 1988 to 1994, NHTSA found that 72.5 percent of 40 states used standardized curricula (primarily NHTSA's) in training courses for prehospital providers (U.S. DOT, 1995). NHTSA's FY 1997 budget for the EMS division responsible for curriculum development is $1.5 million. By virtue of its leadership and support for prehospital training and state highway grants, NHTSA is the federal agency with the most consistent and long-standing presence in trauma systems development (U.S. DOT, 1996b). Certification of prehospital providers also has progressed, with all 50 states having some kind of certification procedure (BLS, 1997). However, there is much variability in requirements for certification (U.S. DOT, 1996b). Thirty-nine states certify prehospital providers who have passed written and practical examinations administered by the National Registry of Emergency Medical Technicians, a nonprofit certifying organization (NREMT, 1998). Yet, most states do not adhere to the registry's biennial reregistration requirement. Less than one quarter of the estimated 650,000 emergency medical technicians (EMTs) nationwide maintained their registration as of November 1997 (W.E. Brown, National Registry of Emergency Medical Technicians, personal communication, 1998). There also has been considerable growth in the field of emergency medicine. The first emergency medicine residency program was formed in 1970. By 1998, the number of accredited residency programs had expanded to 120 (M. Schropp, Society for Academic Emergency Medicine, personal communication, 1998). The first certifying examination was given in 1980, one year after emergency medicine was recognized as a specialty by the American Medical Association Committee on Medical Education and the American Board of Medical Specialties. The number of board-certified emergency physicians catapulted to 15,202 by 1997 (American Board of Emergency Medicine, personal communi-

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Reducing the Burden of Injury: Advancing Prevention and Treatment cation, 1998). The stature of the profession has also improved with the ascension of emergency medicine to full department status in many academic medical centers. Finally, the profession of emergency nursing has grown and flourished. The field emerged as a nursing specialty around 1970, when the Emergency Nurses Association was formed. By 1997, membership in this organization rose to about 24,000, as did membership in related organizations such as the Society of Trauma Nurses. Emergency nurses practice mostly in the prehospital and acute care setting. They typically are responsible for assessing and initiating care to stabilize and resuscitate patients and for care during transport of critical care patients. The role of the emergency nurse in the prehospital arena is continuing to evolve (Adams and Trimble, 1994). ROLE OF TRAUMA SYSTEMS IN PRIMARY PREVENTION, SURVEILLANCE, AND RESEARCH Community-based primary prevention programs have been demonstrated to avert injury-related morbidity and mortality and to reduce health care costs. Trauma care systems have traditionally focused on secondary and tertiary prevention (i.e., efforts to reduce re-injury and to curtail the impact of an injury once it has occurred). Yet consensus has emerged that health professionals who manage trauma patients also should engage in primary prevention to keep an injury from occurring in the first place (U.S. DHHS, 1992; NCIPC, 1993; U.S. DOT, 1996a; Garrison et al., 1997). The rationale for broadening the role of trauma providers to include primary prevention is that these health professionals have unique and direct experience with, and knowledge of, the consequences of injury, as well as a professional obligation to improve health and safety and to control health care costs. After reviewing the biomedical literature on existing and recommended primary prevention activities for out-of-hospital providers (Kinnane et al., 1997), a consensus statement on prevention by the EMS community was prepared under the aegis of the National Association of EMS Physicians. The statement recommended leadership activities and knowledge areas that are either essential or desirable. Some of the leadership activities deemed to be essential were the provision of education to EMS providers on primary injury prevention, the protection of individual EMS providers from injury, and the collection and use of injury data (Garrison et al., 1997). Although a number of primary prevention programs by prehospital. and acute care providers have been implemented in various states or regions, none has been evaluated as yet (Kinnane et al., 1997). The committee suggests that enhanced emphasis be placed on the development and evaluation of prevention programs by these providers, as well as by rehabilitation providers to prevent secondary complications of injuries. Further, the committee believes that primary injury prevention should be incorporated into training curricula and continuing medical education pro-

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Reducing the Burden of Injury: Advancing Prevention and Treatment grams for prehospital and acute care providers. Finally, the committee believes that there are financial incentives for employers, insurers, and others who pay for health care to adopt injury prevention, a point discussed later in the section on health care financing. Surveillance data from trauma systems are indispensable for monitoring outcomes, assessing system performance, determining the etiology and scope of the injury problem in a community, and influencing public policy. Yet no nationwide or nationally representative surveillance systems are operational for trauma systems as a whole nor for their separate elements (i.e., prehospital, acute care, and rehabilitation services). Most surveillance systems currently in place are kept by individual trauma centers as a condition of trauma center designation (Pollock and McClain, 1989).2 In addition, although 48 percent of states have some type of hospital-based trauma registries, there is great variability in their nature, scope, purpose, and data elements (Shapiro et al., 1994). To instill greater uniformity, federal agencies and professional organizations have taken the initiative to develop and encourage the use of a variety of uniform data sets from prehospital, acute care, and rehabilitation providers. Working with the EMS community, NHTSA sponsored a conference in 1993, the final product of which was a proposed set of 81 uniform prehospital EMS data elements, either essential or desirable, for patient severity and treatment, cause of injury, response, and transfer times, but not for outcomes (under the rationale that these would have required linkages to the emergency department) (U.S. DOT, 1994). CDC's National Center for Injury Prevention and Control (NCIPC) supported the development of a uniform data set for 24-hour, hospital-based emergency departments, the Data Elements for Emergency Department Systems (DEEDS) (NCIPC, 1997a). The ACS developed, specifically for trauma centers, the National Trauma Data Bank to serve as a voluntary national repository of data from trauma centers. The Uniform Data System for Medical Rehabilitation was developed with support from the National Institute on Disability and Rehabilitation Research to capture the severity of patient disability and the outcomes of rehabilitation. A number of states and regions have implemented laws that mandate inclusive trauma systems with comprehensive trauma registries. These registries include data retrieved from prehospital services, police and ambulance records, hospitals, rehabilitation centers, and medical examiners' files. These data systems are driven by E-codes (see Chapter 3) and have disease- and severity-specific information, as well as length of stay, morbidity and mortality, and charge information. Linkages between data sets covering prehospital, acute care, and rehabilitation providers are envisioned as a pivotal means of integrating information across trauma systems nationwide and of formulating public policy. 2 ACS criteria require Levels I–III to collect minimal registry data, whereas Level IV is encouraged, but not required, to maintain a registry.

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Reducing the Burden of Injury: Advancing Prevention and Treatment However, experience thus far points to the difficulty of performing such linkages for outcome studies (Copes et al., 1996). The committee supports the widespread adoption of uniform surveillance data sets, such as those recommended by NHTSA for prehospital care, by NCIPC for emergency department care, and by the ACS for trauma centers. Once adopted, demonstration projects should be developed to determine the most cost-effective means of establishing linkages between prehospital care, acute care, and rehabilitation data sets. Research has been instrumental in the evolution of trauma systems. It has formed the underpinning for improved patient care and survival, reduced morbidity, and a national investment in trauma systems. In recognition of its vital role in advancing the trauma field, the ACS requires Level I trauma centers to conduct an active research program. Nevertheless, many prehospital, hospital, and rehabilitation providers do not participate in basic or clinical research, despite the existence of major gaps in knowledge across the entire spectrum, from basic research in tissue injury to health services research in trauma care systems. There is a dearth of funding for research on trauma systems design, effectiveness, and cost-effectiveness. The existing research support is fragmentary at best, and there is no critical mass of support and leadership. The modest level of support comes mostly from NCIPC and the Agency for Health Care Policy and Research (AHCPR) (NCIPC, 1997b). NCIPC has sustained an investment in trauma systems research, even though its extramural research program is beset by funding limitations. The overall problem is that trauma systems research falls under health services research, an area that has not fared well in the research hierarchy and competition for resources. Health services research, despite a critical need, is a field whose recognition and importance have come only in the past decade, at a time of persistent pressures to reduce the federal budget deficit. Health services research has not grown to a level commensurate with its significance to society. As the major benefactor, AHCPR is among the newest and least-endowed agencies of the U.S. Department of Health and Human Services. The purview of AHCPR extends well beyond trauma systems to cover all areas of clinical practice. Expectations for a research center at the National Institutes of Health were temporarily aroused in 1994 with the publication of A Report of the Task Force on Trauma Research , a congressionally mandated report for research recommendations to launch a trauma research program, including research in trauma systems (NIH, 1994). However, the report went largely unnoticed; Congress did not appropriate funds for its implementation. A subsequent section of this chapter contains a recommendation to augment trauma systems evaluation and related research. GROWTH IN TRAUMA CARE SYSTEMS All indications point to a progressive increase in the development of trauma systems in the United States since the 1970s, yet documenting the growth is not

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Reducing the Burden of Injury: Advancing Prevention and Treatment being driven more by cost containment pressures than by empirical evaluation to ensure their effectiveness in matching patient needs with available resources. With one exception (Neely, 1998), very few such evaluations have been published thus far. Managed care has extensively penetrated rehabilitation services in some major cities and is growing rapidly elsewhere (DeJong et al., 1996). There is a paucity of research on the impact of managed care on rehabilitation services. So many questions remain unanswered that a blueprint for research on managed care and people with disabilities has been developed (U.S. DHHS, 1995; IOM, 1997a). Although 70 percent of working Americans are enrolled in managed care, the need to demonstrate the relationship between quality of trauma care and rehabilitation and costs and outcomes is important for all Americans. This information is needed for defining best practices and for shaping treatment guidelines. It is also essential to the development of innovative service delivery models that benefit the patient while attending to the escalating costs of health care. The committee recommends intensified trauma outcomes research, including research on the delivery and financing of acute care services and rehabilitation. The committee envisions that HRSA and other appropriate federal agencies (e.g., NCIPC, AHCPR) will collaborate on this research. Specific areas of research that should be addressed include the following: the cost-effectiveness of specific clinical and service interventions to establish best practices in trauma care; the most efficient and effective strategies for organizing and financing the delivery of both acute care services and rehabilitation, including the impact of managed care arrangements on access to services, quality of care, and outcomes; and the development of improved methods for measuring the severity of injury, particularly for those at high risk of adverse outcomes. Finally, managed care accrediting organizations should support the development, coordination, and implementation of trauma care systems. They should mandate, as a condition of facility accreditation, participation in an inclusive trauma care system in states and regions with such systems and should promote the development of trauma care systems in states and regions without them. SUMMARY Great strides have been made over the past decades in developing trauma systems covering a continuum of prehospital, acute care, and rehabilitation

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Reducing the Burden of Injury: Advancing Prevention and Treatment services. Public health organizations and providers have embraced the need for a broader, more inclusive philosophy that shifts the focus from the trauma center to a system of trauma care that attends to the needs of all trauma patients over the full course of treatment. Trauma care is lifesaving, yet expensive. The costs of trauma systems development should be shared by federal, state, and local governments. About half of the states report having some kind of trauma systems, although their nature and extent are not well documented. Some of the most successful statewide trauma systems have flourished with dedicated sources of funding through motor vehicle fees and other creative approaches. Research has begun to demonstrate that the investment in systems of care can be cost-effective in terms of long-term health care costs and productivity. However, there always may be vulnerable populations, such as the elderly, for whom cost-effectiveness may be difficult to demonstrate. More research is needed on vulnerable populations, patient outcomes, system configuration, and cost-effectiveness. A focal point at the federal level has to be reinstated to support research and to cultivate the growth of state and regional trauma systems. A federal program had been in place until 1995, when budget pressures led to the program's demise. The financing of patient care continues to constrain trauma systems. The growth of managed care has placed further financial burdens on hospitals and trauma centers. The impact of managed care on trauma patient access, utilization, quality, and financing is essential to monitor but has been largely unexamined in the peer-reviewed biomedical literature. Financing constraints reinforce the public health imperative of primary injury prevention. REFERENCES AAAM (Association for the Advancement of Automotive Medicine). 1990. The Abbreviated Injury Scale. Des Plaines, IL: AAAM AAAM (Association for the Advancement of Automotive Medicine). 1994. The Injury Impairment Scale, 1994. Des Plaines, IL: AAAM. ACEP (American College of Emergency Physicians). 1992. Guidelines for trauma care systems. Annals of Emergency Medicine 22:1079–1100. ACEP (American College of Emergency Physicians). 1993. America's Health Care Safety Net, Emergency Medicine: 1968–1993 and Beyond. Dallas, TX: ACEP. ACEP (American College of Emergency Physicians). 1998. ACEP [World Wide Web document]. URL http://www.acep.org (accessed January 1998). ACS (American College of Surgeons). 1993. Resources for Optimal Care of the Injured Patient. Chicago: ACS. ACS (American College of Surgeons). 1995. Trauma funding is threatened. Bulletin of the American College of Surgeons 80:7. Adams BL, Trimble MP. 1994. Nurses. In: Kuehl AE, ed. Prehospital Systems and Medical Oversight, 2d edition. St. Louis: Mosby-Year Book. Pp. 76–80. Baker SP, O'Neill B. 1976. The injury severity score: An update. Journal of Trauma 16(11):882–885.

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