Regionalized health care and the trauma system model

The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.

The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.

National Trauma and Acute Care Surgery Center Network: A Proposal

I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.

Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).

Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.

A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.

The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.