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In the United States, an estimated 57 million persons were involved in traumatic injuries per year with a lifetime direct cost to the nation of $156.6 billion, according to data 20 years ago.1 Today, the cost has grown exponentially and is closer to $400 billion per year.2 Trauma is the leading cause of death in those younger than age 37, and the incidence of death among the injured older than age 65 is disproportionately higher. The mortality is at least doubled in the older population (>65 years) given matched injury severity scores when compared to the younger population.3 The effect of trauma on the geriatric population is only beginning to manifest as the baby boomers age.
In an effort to meet the demands of trauma, the development of systems to treat these patients more effectively and efficiently has become a prominent goal of several organizations. How to do this continues to be in the forefront of trauma design efforts and studies. As a result of lessons learned from the military's experience in Korea and Vietnam, quick transport of injured patients to a trained trauma team became the focus of trauma systems. In the military, it became clear that the incidence of those killed in action precipitously decreased as a direct result of quick transport to fully functioning medical units capable of providing expert care and resources.4 After stabilization at these Mobile Army Surgical Hospitals (MASH) in Korea (today's forward surgical team), the patients were transferred to a higher echelon of care in a rapid and effective fashion. Throughout the 20th century, many municipal urban hospitals have become established centers of excellence for trauma and have paralleled the military's experience.4 It became clear that outcomes improved by establishing a system to deliver the most acutely injured patient to a hospital that had people focused on issues of trauma care and technique. However, an overall ability to develop and organize the trauma systems outside the urban environment was still lacking. Physicians became frustrated that, despite their expertise in trauma, patients were not being transferred to their teams. In 1966, the publication of Accidental Death and Disability: The Neglected Disease of Modern Society by the National Academy of Science/National Research Council (NAS/ NRC) Committee on Trauma of the Division of Medical Sciences led the government to take a more active role in the support of trauma research and system development.5 This publication called for the development of four levels of care ranging from first aid centers to fully functioning surgical hospital centers. It also called for federal funding to establish a National Institute of Trauma within the Public Health Service. This recommendation has failed to be fulfilled primarily because of a lack of funding.4
Congress responded to this publication by enacting the National Highway Safety Act of 1966, and the Department of Transportation (DOT) was given authority, money and instruction to implement the law. This bill resulted in the development of research that ultimately led to a decrease in mortality and morbidity from car crashes. It also paved the way for better communications systems and the use of helicopters for medical evacuation. Maryland, Florida and Illinois took advantage of the federal funding provided by the National Highway Safety Act and developed new concepts in trauma system design. Maryland, under the direction of R. Adams Cowley at the Maryland Institutes for Emergency Medicine, the University of Maryland and the Maryland State Police, cooperated in a unique program in 1969. Patients were transported from the scene and from referring hospitals by state police helicopters to the shock trauma center.6 The program resulted in a reduction in mortality directly related to the rapid transport of patients.
In Jacksonville, Florida, there was a 38% reduction in the frequency of deaths related to motor vehicle crashes after implementing an emergency medical care system.7 Also, Illinois developed a statewide trauma system that designated selected hospitals as trauma centers. It also called for better communication technology, better design of ambulances, special training for healthcare professionals, a program for evaluation and a database developed as a trauma registry. 8,9,10
It was also during this era that the Committee of Trauma of the American College of Surgeons (ACS/COT) took a central role in the leadership of trauma system development.11 The ACS/COT in 1976 published the first edition of Optimal Hospital Resources for Care of the Seriously Injured, a resource used currently (in its latest 1999 edition) as a manual guiding hospitals to be credentialed by the ACS/COT as a trauma center. In 1981, federal funding sharply declined for the development of regional emergency medical systems as a result of the Omnibus Budget Reconciliation Act of 1981. This act stopped federal funding for support of emergency medical services (EMS) and changed the way states could use the remaining funding.4 Many states shifted the remaining funding away from the EMS system to other state agendas. In 1983, after authorization from the DOT, the NAS/NRC conducted a follow up of the 1966 publication. This review determined that trauma was still a major problem and that continued research, education, and system developments were necessary. 12 This prompted the development of a federally funded Center for Injury Control, established within the Centers for Disease Control of the Department of Health and Human Services.
More Work Ahead
Despite these efforts, the development of trauma systems is progressing disproportionately slowly compared to the need for them. Trauma system design lacks the solid funding structure necessary to support proper development. The evidence supports the notion that trauma systems improve outcomes. However, there is little research on how to fund and implement statewide systems. In 1999, Nathens et al published a study that used the trauma system inventory published by the Health Resources and Services Administration (HRSA).13 They looked at the overall mortality in those states with trauma systems versus those without systems. There was a 9% decrease in mortality in those states with trauma systems.
In 2002, the HRSA published its latest survey results, which allow one to follow development in a finite number of trauma system categories. This survey used previous surveys and collaborations with leaders in the field of trauma system development. The questions stemmed from West's assessment of eight criteria in 1988. This allowed a temporal account of this development. The number of states that have legal authority to designate trauma centers rose from 19 in 1988, to 20 in 1993, and to 39 in 1998. In 2002, 38 states were recorded. These numbers are misleading due to differences in how states were surveyed and what criteria were used to determine whether states have adequate legislation in place.14 Today, 35 states have a formal process for designating trauma centers, and all these states use American College of Surgeons (ACS) standards for trauma center designation.15 Only eight of these 35 states limit the number of trauma centers based on community needs. This is based on the unproven concept that limiting the states' trauma centers will focus necessary resources and personnel because of the limited financial resources. This focus is thought to lead to a more efficient and effective use of resources and improve outcome. Although the idea of a trauma system institution has improved outcomes, this concept is still in debate and in need of study and evaluation. However, as more data illustrate the increasing need for trauma system maturation, a call for study of how to fund and best regulate these new systems is necessary. |
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