Evaluation of a mature trauma system.

The necessary components of an inclusive trauma system were first outlined in the Model Trauma Care Systems Plan published by the U.S. Bureau of Health Resources Development in 1992.1 In an inclusive system, patients with minor to moderate injuries may be treated at nontrauma centers (NTC) with the goal of matching the needs of the patient to the resources of the facility. One of the necessary components of the system is periodic evaluation to assess performance of the system and to determine if modifications are required.2–4 This evaluation may be difficult because of a number of factors. First, accurate data may be difficult to obtain because, while the trauma centers (TC) maintain trauma registries, there are no requirements for nontrauma acute care hospitals to maintain a database of trauma patients.5,6 Second, it may be difficult to demonstrate a survival advantage attributable to treatment at a TC because in a mature trauma system with adequate triage, delivery of seriously injured patients to TCs means that the patients with the largest risk of dying will be clustered in these centers.7 Thus, it would not be unexpected to observe an increased or unchanged mortality risk in TCs in a mature system.8–11 In addition, a “halo effect” may be seen with the maturation of a trauma system. This effect results in improved survival of injured patients regardless of whether they are treated at a TC.12 Shortened EMS response times, improved prehospital medical control, and the performance of airway and resuscitation interventions by emergency medical services personnel have been demonstrated to improve clinical outcomes whether the patient is transported to a TC or a community hospital.13 Finally, the assessment of the cost-effectiveness of a trauma system relies on the return of trauma victims to a productive life. This requires longitudinal follow-up of large groups of patients. This may be difficult to achieve given the limited data sources available. Because of these challenges, few studies have been able to evaluate the effectiveness of mature inclusive trauma systems. The Florida trauma system was established in 1982 when legislation was passed requiring the Florida Department of Health (DOH) to designate individual TCs based on the American College of Surgeons standards. The Roy E. Campbell Trauma Act, passed in 1990, set up a system of state approved trauma centers. In 1998 the DOH's Bureau of Emergency Medical Services (EMS) provided a report to the legislature entitled “Timely Access to Trauma Care,” which examined the feasibility of establishing a prehospital triage plan to ensure that trauma patients were transported to the closest appropriate TC. This report laid the groundwork for Florida to establish an inclusive trauma system in 1999 when legislation was passed directing the DOH to plan, coordinate, and establish a 5-year plan for a statewide trauma system. Despite having a long-standing trauma system, Florida has never provided a durable source of funding to support the system. Cost and manpower concerns have resulted in tensions within the trauma system such that over the life of the system the number of trauma centers has declined from a high of 66 TCs in 1987 to 21 TCs in 2004. During 2003 to 2004, 2 additional trauma centers were threatened with closure. One of these centers was 1 of the 6 level I centers for the state and the only center serving a city with a population of nearly 1 million. This crisis was solved, at least temporarily, by a coalition of local government and hospital leaders who were able to arrange funding for support of trauma patient care. State government support of the Florida trauma system has taken the form of an annual appropriation to each trauma center as well as favorable payment methodologies for trauma centers via the Medicaid insurance system. In May 2004, Governor Bush vetoed the funding bill that would have continued the annual award of grants providing equal amounts of money to each trauma center. In the veto message, the Governor cited the potential inequities of a funding method that awards a set amount to each trauma center regardless of the number of patients served, the absence of a clear plan for the future deployment of trauma system resources, an absence of a clearly articulated plan for consistent local participation in the financial support of the trauma system, and the need to document the effectiveness of the trauma system. Regarding the issue of effectiveness, the Governor stated “Trauma centers save lives, but so do hospitals that are not designated trauma centers. What is the difference derived from adherence to our (trauma system) regulations? If state government is to initiate trauma center unique payments, we must first know we are paying for performance.” The surviving legislation from this bill mandated a study to be funded to ascertain the need for local and state funding for the trauma system, determine the best deployment of the system, and provide outcome data to ensure that the system does confer a survival advantage. The purpose of this paper is to outline the methodology used to evaluate a mature inclusive trauma system such as the one found in the state of Florida and to answer 3 questions: 1) Does treatment at a TC versus a NTC improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable?