After four and a half years of struggle, Chicago this month will implement an ordinance that’s expected to create an exemplary trauma care system. The ordinance, which incorporates a trauma-classification system designed by the American College of Surgeons, was backed by the local hospital council and other health care groups. Yet a similar trauma care proposal languishes in the Illinois legislature, opposed by even the state hospital association.
In 1971, Illinois’ trauma system was a model for other states, but it quickly eroded because of loss of funding, interest, and effort, says Ted Matson, program manager for the American Hospital Association’s Division of Ambulatory Care, Chicago. After 1973, the state never reinspected or recertified the few trauma centers it designated, he says.
Those hospitals originally deemed trauma centers want a guarantee that they’ll be redesignated –or, at least, that their local competitors won’t get the designation either, says Anthony Marquez, chief of emergency medical service operations for the Illinois Department of Public Health, Springfield, IL. “It’s unbelievable how fierce the competition is.”
The myths. The reason for Illinois’ situation has as much to do with myth as with competition, says Matson, who sees Illinois as a microcosm of the national status of trauma care: a few bright spots amid general disorganization.
“There are three perceptions that hospitals have about trauma centers that just aren’t true,” he says. “The first is that if your hospital isn’t one of those designated as a trauma center, then your emergency department visits will significantly decrease. The second is that a hospital without trauma-center designation will lose substantial revenue to a hospital that is designated a trauma center, because trauma care is high-cost treatment. The third is that if your hospital isn’t designated a trauma center, you lose prestige to the hospital that is designated and thereby also lose potential non-trauma patients.’
To debunk these myths, Matson cites a study of the trauma system in Orange County, CA. The study compared emergency department (ED) visits at the county’s five designated trauma centers to those at the 30 undesignated hospitals in the area. The study showed no significant change in ED visits after implementation of the trauma system–no change for either the trauma centers or for the other hospitals.
Another myth. The study was conducted by Richard Cales, M.D., chief of emergency medicine at Portland (OR) Adventist Medical Center. Cales, who is also chairman of the trauma committee of the American College of Emergency Physicians (ACEP), adds another item to Matson’s myth list–the myth that any hospital can handle trauma cases.
“Hospital administrators have been telling people for years that “our emergency room can handle anything.’ Don’t you believe it,’ Cales warns. “Trauma care is tertiary care. It meets all of the criteria regarding volume and special skills–and if you’re going to provide tertiary care to this kind of population, you have to have a system. When you start talking about trauma care as tertiary care, administrators get a whole different mind-set.’
The truths. It isn’t the trauma centers but the “doc-in-the-box’ walk-in centers that compete with hospital EDs, says AHA’s Matson. “We know . . . that hospitals that promote their EDs have increased their visits. We’ve seen that both for hospitals that have received trauma center designation and for those that have not.’
Based on October 1985 AHA data, ED visits were up by about 4 percent nationally from the previous year, Matson notes, partly because “there’s been a general reorganization of EDs toward a more consumer-oriented approach.’
The revenue myth also is dispelled by the Orange County, CA, study. Although serious trauma cases require more effort and resources, they represent a tiny fraction of ED visits. For that matter, “less than 5 percent of all trauma patients require level I care,’ Cales adds.
The Illinois dilemma. The Human Services Committee of the Illinois House is trying to put together a revised bill that would be limited mostly to enabling legislation. Why? Because Illinois doesn’t have a structure in place to let it organize and review its 26 existing trauma systems–and because a comprehensive trauma-system bill wouldn’t pass at this point, says a Democratic legislative aide, who asked not to be identified. Many hospitals outside Chicago still believe the myths and oppose any law they think would take patients from them,” he explains.
“Lots of downstate hospitals are sole providers, who don’t want to spend the money to upgrade to a level II status,’ adds Patrick Finnegan of the Metropolitan Chicago Healthcare Council. “They’re afraid it’s going to cost too much.”
Political battles. Meanwhile, Finnegan notes, the Illinois Hospital Association (IHA) “is caught in the middle: It has to represent all the hospitals in the state.’ Scott Malan, an IHA lobbyist, concedes that the trauma bill has created considerable dissent among IHA members.
Malan points out that it’s difficult for hospitals to tell from the bill’s first draft whether they could qualify for trauma-center designation; the criteria weren’t included in the bill. However, the proposed legislation was being amended at Hospitals’ deadline.
The first draft also includes a certification requirement for trauma centers, which is opposed by IHA as duplicative and over-regulative, Malan says. IHA testimony before the legislative committee expressed concern that standards previously developed by the state’s emergency medical services council would be too rigid for downstate hospitals to be able to qualify for level II or level III status. Most level I centers are teaching hospitals.
The rebuttal. “It’s totally ridiculous for most of them to try to upgrade to a level II. You only need a few level II trauma centers evenly distributed across the state,’ retorts ACEP’s Cales. “There are hospitals that could easily qualify as level II trauma centers, but they’re goint to be in cities of 100,000 or more.’
Then what’s the real issue? “The real problem in rural areas is that the local hospitals will literally fight to the death to keep these patients [rather than transferring them to the larger facilities]. Either the patients aren’t recognized as being seriously injured, or– even if they are–the local hospital overestimates its capability of caring for them,’ says Cales. “You’re going to lose a few patients during transfer, but that doesn’t justify not taking a hard look at the problem. We call it “high-sick, low-sick’ –you have to know which patients are high-sick and send them on, if necessary.’
The requirements. The key to a good trauma center, Cales says, is local physician commitment, “not going out and buying a lot of equipment. As long as you have people who are willing to stay on their toes, nobody has to sleep over at the hospital all the time.’
But the trauma center has to be part of a system, he adds. “You need statewide coordination. You can’t do it any other way. No place that has ever tried it on a piecemeal basis has succeeded’–and that’s something for Illinois legislators to keep in mind, he notes. The trauma-center bill is scheduled to advance out of committee early this month.