Chapter 26 Jeffrey P. Salomone and Joseph A. Salomone In its broadest sense, a trauma system consists of both an organized approach to managing patients who have suffered acute injury, across the continuum from initial medical care through rehabilitation, as well as injury prevention activities aimed at those at risk of suffering trauma. While the trauma system should be integrated with both public health and emergency management, there is significant overlap between trauma and EMS systems. This chapter will focus primarily on the close interaction between these two systems. Trauma systems are typically organized on a state-wide basis, although some larger counties may have sophisticated systems (e.g. San Diego County, CA). In 1988, West and colleagues described the ideal criteria for a state-wide trauma care system (Box 26.1) [1]. State laws generally delegate the authority for designation of trauma centers to a state agency, such as a department of health, and describe the process by which hospitals may seek designation. Because of their close relationship, most state trauma offices are colocated with the state office of EMS. While most states utilize the standards promulgated by the American College of Surgeons Committee on Trauma (ACS-COT) [2], some states (e.g. Florida) opt to draft their own trauma center criteria. The term “designation” refers to authorization from a state agency for an institution to represent itself to the public as a trauma center, while “verification” refers to the inspection by a non-biased team of experts (usually from outside the community) who have confirmed that all necessary services and processes are in place to meet the ACS-COT (or equivalent) standards. In the ideal trauma system, the lead agency would have the authority to designate trauma centers based upon need, rather than simply approving any facility that desires designation in a competitive, free-market approach. Need for additional trauma centers should be based upon the population of a geographic area, the volume of trauma patients encountered, or proximity to other designated centers. Trauma centers that regularly see large numbers of patients are able to maintain readiness so that management becomes a matter of routine practice, while those that fail to see sufficient numbers of injured patients, especially the seriously injured, may find that their personnel struggle to maintain their organizational processes and procedural skills. Like the trauma centers themselves, performance improvement is a key component of a trauma system. Data collected in trauma registries are pooled on a system-wide basis and analyzed. This information may provide insight for focusing injury prevention activities in addition to opportunities for improvement in system design or the need for education. Over the past few years, the ACS-COT has developed the Trauma Quality Improvement Project (TQIP) which conducts risk-adjusted analysis of outcomes at trauma centers that voluntarily participate. By presenting its data as observed-to-expected ratios, TQIP allows centers to voluntarily benchmark themselves to other centers across the country. When fully implemented, TQIP will allow high-performing trauma centers (low observed-to-expected ratios) to share best practices with lower performing facilities (high observed-to-expected ratios). Most states have trauma advisory committees composed of individuals who represent stakeholder sectors involved in trauma care in that state. These committees provide oversight and advise the state trauma office on matters related to improvements in their trauma system. These committees often draft or approve a state trauma plan that serves as a strategic blueprint for enhancing the system over a period of time. Often the state trauma advisory committee also assists the state in determining how governmental funding, if available, will be distributed to stakeholders in the trauma system. This funding helps offset the expensive costs of maintaining trauma center readiness and data collection for trauma registries and aids with the uncompensated care delivered by these centers. State funding may also help provide education to individuals who care for trauma patients and may even purchase some needed equipment. Trauma centers represent one of the essential components of a trauma system. A trauma center is an institution committed to the care of injured patients across the spectrum of initial resuscitation through rehabilitation, including operative management and critical care. A trauma center is a unique blend of personnel (surgeons and other physician specialists, nurses, and allied health care workers), equipment, and processes (robust ongoing performance improvement program). The various physicians, nurses, therapists, and technologists must work together as a cohesive team, under the direction of the trauma surgeon. The most widely accepted criteria for trauma center designation are those promulgated by the ACS-COT [2].
Trauma Systems of Care
Introduction
Trauma system organization
Trauma care facilities
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