Chapter 4: Trauma Systems, Triage, and Transport

A trauma system is an integrated collaboration of agencies and institutions organized to control the disease of injury. Its mission extends from effective prevention and public education to efficient societal reintegration of injury survivors. At the system’s core is coordinated and comprehensive care of acutely injured patients within a defined geographic area.^1,2,3 Its services are multidisciplinary, comprehensive, and encompass a continuum that includes all phases of patient need.^2,3,4,5,6

Trauma System Goals

Because geographical coverage exceeds that of a single hospital or health system, trauma systems provide seamless regionalization of resources to facilitate efficient use of available and qualified health care facilities within a defined geographic area. Cost efficient and efficacious coordination of resources is a defining characteristic of an effective trauma system. Disaster preparedness is also an important function of trauma systems. The institutions and agencies that form the trauma system are, by default, the platforms from where the regional response to care for victims of natural or manmade disasters are coordinated. The US Department of Health and Human Services has compiled a set of guidelines and standards for Model Trauma System Planning and Evaluation.⁷ This comprehensive document is an excellent source of information for every aspect of trauma system design and planning.

Transforming From Exclusive to Inclusive Trauma Systems

Elimination of preventable death by ensuring expeditious access to the resources of a designated trauma center is predicated on the recruitment of institutions committed to providing these resources. The need for triage of acutely injured patients at risk of death or disability to these centers resulted in development of field triage systems to identify those patients. Trauma systems thus evolved as networks of high capacity centers available for all injury victims, especially those at greatest risk. As understanding of what is required for efficacious population based management of the disease of injury has progressed, it has become clear that effective control of this disease requires participation of the entire community. To achieve optimal control of the disease of injury, systems that had developed for the exclusive care of the most severely injured required transformation to an inclusive regional enterprise that address all phases of injury control. This included effective integration and collaboration of designated trauma centers with all regional health care facilities. As American health care system shifts from reaction to patient disease to preemptive management of population wellness all trauma systems must be configured as inclusive.

The Nature of the Disease of Injury

The disease of injury affects all age groups with devastating personal, psychological, and economic consequences. Analysis of regional, national, age, and gender specific mortality for 240 causes of death comparing 1990 to 2013 clearly defines the primacy of injury as a global threat, especially to the young.⁸ There are huge discrepancies among nations and within various parts of the world. Many developed countries with resources to support trauma systems have experienced a decrease in trauma mortality, in contrast to less developed regions where injury remains a major killer, especially for those trapped in continuing civil strife. A recent report to Congress estimated that more than 50 million Americans sustained an injury requiring medical care in 2000, resulting in estimated lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity.⁹

The modern approach to trauma care is based on lessons learned during war. Combat casualty care has been, and remains a major stimulus to the evolution of surgical care.¹⁰ Advances in rapid transport, volume resuscitation, management of complex injuries, surgical critical care, early nutritional therapy, deep venous thrombosis prophylaxis, and most recently, damage control resuscitation have all derived from wartime military experience.^11,12

History of Trauma System Development

The modern timeline of development of comprehensive trauma care began in 1949 when the American College of Surgeons Committee on the Treatment of Fractures, which had been established in 1922, was expanded to become the American College of Surgeons Committee on Trauma (ACSCOT). In 1961, a dedicated trauma unit was opened under the leadership of R. Adams Cowley, MD FACS, at the University of Maryland. The National Academy of Sciences and the National Research Council published Accidental Death and Disability: The Neglected Disease of Modern Society in 1966.¹³ This redefinition of injury as a preventable and treatable disease was a major stimulus to the development and propagation of systems of trauma care.

By 1973, Dr Cowley’s initiative engendered the Maryland Institute of Emergency Medicine, which became the first completely organized, statewide, regionalized trauma system. A similar initiative which included designation of trauma centers by state law was begun in 1971 in Illinois.¹⁴ Virginia followed suit in 1981, and established a statewide trauma system based on volunteer participation and compliance with national standards as defined by the ACSCOT.

In 1973, the Emergency Medical Services Systems Act became law, providing guidelines and financial assistance for the development of regional EMS systems. State and local agencies instituted prehospital care systems to deliver patients to major hospitals where appropriate care could be provided. Prehospital provider programs were standardized, and training programs were established for paramedics and emergency medical technicians (EMTs).

The American College of Surgeons published the first edition of the Optimal Hospital Resources for the Care of the Seriously Injured in 1976, establishing a standard for comprehensive delivery of trauma care. This document was the first to define specific criteria for the categorization of hospitals as trauma centers. The document is periodically revised to reflect current thought, and is recognized nationally and internationally as the standard for hospitals aspiring to be trauma centers. The most recent 6th edition entitled Resources for Optimal Care of the Injured Patient: 2014 was published in 2014.⁴ In addition to establishing evidence based criteria for prehospital and trauma care personnel, the 6th edition emphasizes the importance of ongoing performance and quality improvement.

ACSCOT developed the Advanced Trauma Life Support (ATLS) course in 1980, motivated in part by the personal experience of a surgeon involved in the crash of his private airplane. His own experience and his observations of the care provided to members of his family made him realize that more education about resuscitation and care of the injured patient was critically needed. The resulting ATLS course has contributed to the uniformity of initial care, has developed a common language for all care providers, and has been successfully promulgated throughout the world.

In 1985, the National Research Council and the Institute of Medicine published Injury in America: A Continuing Health Care Problem. This document concluded that there had been little progress toward reducing the burden of injury despite considerable funding committed to develop trauma systems.¹⁵ It also recommended investment in epidemiological research and injury prevention. As a result the Centers for Disease Control and Prevention (CDC) was designated as the national research center, to coordinate efforts at the national level in injury control, injury prevention, and all other aspects of trauma care.

In 1987, the ACSCOT instituted the Verification/Consultation Program to provide resources for trauma center verification. More recently, the ACSCOT added additional focus on systems development with publication of Consultation for Trauma Systems to provide guidelines for trauma system evaluation and enhancement.¹⁶ Concomitant with these efforts, the American College of Emergency Physicians (ACEP) published Guidelines for Trauma Care Systems.¹⁷ This document also addressed the continuum of trauma care and identified essential criteria for trauma care systems.

In 1988, the National Highway Safety Administration (NTHSA) established the Statewide EMS Technical Assessment Program and the Development of the Trauma Systems Course, both important tools to assess the effectiveness of trauma system components as well as support for ongoing system development. NHTSA also developed standards for EMS quality assessment, including trauma care. These standards required that the trauma care system be fully integrated into the state’s EMS system and be supported by enabling legislation (Table 4-1). The trauma care component must include designated trauma centers, transfer and triage guidelines, trauma registries, and initiatives through public education and injury prevention. In 1990, the Trauma Systems Planning and Development Act created the Division of Trauma and EMS (DTEMS) within the Health Resources and Services Administration (HRSA) to improve EMS and trauma care. Unfortunately, the program was not funded between 1995 and 2000, as many states were in the process of developing trauma systems. Two initiatives from this legislation are noteworthy: (1) planning grants for statewide trauma system development were provided to states on a competitive basis and (2) the Model Trauma Care System Plan was published as a consensus document. The Model Trauma Care System Plan established an apolitical framework for measuring progress in trauma system development and set the standard for the promulgation of systems of trauma care. The program was again funded in fiscal year 2001 but lost funding in 2006. New legislation is currently under consideration by the 114th Congress. The newest document for trauma system planning uses the public health care model of assessment, policy development, and evaluation of outcomes. With appropriate federal funding, this approach should be very successful.⁷

Modern Challenges

The evolution of trauma systems reflects two very critical elements of modern health care. First is the obvious mandate to ensure that properly trained and experienced personnel with the right equipment are immediately available for every injured patient. Linked to this is the reality that this extensive and intensive investment in personnel and resources demands accountability defined in better outcomes, more cost effective, efficacious care, and good stewardship of expensive resources. The disease of injury is expensive to treat. Its impact in terms of ongoing chronic care costs and lost human productivity are enormous, and not completely measurable, especially when the factor of diminished quality of life for survivors and their families is considered.

The current transformation of the health care system in the United States is focused on increased patient coverage, improved quality of care, and lower cost. This is often defined in terms of the triple aims of better care, lower cost, and improved population health.¹⁸ From the perspective of trauma systems these goals demand careful and ongoing review of the overall performance and effectiveness of every component of the system. The critical factor that guides planning of a trauma system is the balance of injury risk versus total cost of disease control sustained by the specific population to be served. While the ideal concept might be a designated trauma center within 5 minutes of ground transport for every citizen, the cost of maintaining such a network and the dilution of skills in management of severe, multiorgan injury would increase societal cost with no guarantee of improved clinical outcomes. In fact, the likelihood of inexperience driving unnecessary or avoidable cost is significant. The converse is also problematic. Too few trauma centers will almost certainly lead to an increase in preventable mortality, especially if access requires long-distance transport. From a population-based perspective, trauma system performance must be measured in terms of efficacy in maintaining wellness (injury prevention), and efficiency in treatment of injury victims (outcome). The population of injury victims is skewed toward a majority with non–life-threatening injury for whom timely, appropriate care should produce optimal recovery and avoidance of unnecessary expense. To this is added a complex core of severely injured who demand multidisciplinary care from qualified providers whose experience can contribute to optimal outcome in a cost-effective manner. Thus, in the emerging, modern health care environment, an accountable trauma system must balance the competing mandates of immediate access to the care of qualified, experienced personnel in designated facilities against unnecessary cost to the entire population generated by inappropriate replication of expensive resources.¹⁹ In a statement released in February 2015, the ACS emphasized the importance of controlling allocation of trauma centers. It reiterated that designation of trauma centers based upon regional population need has been recognized as an essential component of trauma system design since the 1980s.²⁰ Nonetheless, few trauma systems are currently able to operationalize these concepts, especially when faced with real or potential challenges that stem from powerful health care institutions or providers.

Processes of Trauma System Development

The critical milestones necessary to support statewide EMS and trauma system development as initially defined by West et al are listed in Table 4-1. Attainment of these criteria is a stepwise progression that begins with definition of need.^1,4 Historically, this has been accomplished by reviewing the outcome of regional trauma cases with special focus on preventable deaths.^21,22 The first step is to establish legal authority for system development. This usually requires legislation at a state or local level that provides public agency authority. The legislation must authorize the agency to define criteria for participation, establish a trauma registry as a fundamental component for system quality assurance, and implement processes for verification and designation. The surgeon’s role in articulating need and in guidance of system planning is critical in both leadership and commitment to optimal care. Designation must include continuous reporting of objective metrics of accountability from designated centers. The other critical component of authorizing legislation is adequate appropriation of resources for ongoing system management, which must include periodic needs assessment, assurance of fiscal solvency, and continuous focus on clinical outcomes.

One of the most critical components to be assessed in the deployment of a trauma system is cost, both in implementation and in ongoing system maintenance (Table 4-2). While the major goal of an inclusive trauma system is complete control of the disease of injury along the entire spectrum of prevention to successful societal reintegration of injury victims, reality dictates that each component of this ideal system have an adequate financial base to support its mission. The ideal is that any injured patient obtains immediate access to an appropriately designated trauma center. Unfortunately the cost of the ideal must be balanced against what is financially sustainable. The determination of need for a trauma center must first reflect its contribution to the overall capability of the trauma system to manage the disease of injury in the population being served. Part of this assessment must include overall taxpayer cost. As previously stated, too few trauma centers do not adequately serve the population, resulting in a more profound effect of injury on human productivity and longitudinal cost of care. Too many trauma centers produce unnecessary overhead to population health care costs, avoidable duplication of services, and potential dilution of provider skills in management of complex cases.²³ Trauma system funding parallels the challenges of providing coverage for individual patients. A “free-market” approach that would enable any hospital to establish a trauma service verified by an appropriate national organization would place the burden of financial viability on the business cycle of the hospital. National verification would assure that acceptable quality of care is widely available but the fiscal solvency of any trauma service would be sensitive to payer mix, resulting in financial stress to those facilities that serve unfunded patients. Subsidizing these hospitals with public funds to cover gaps in reimbursement adds an additional financial burden to all taxpayers, since a portion of all tax dollars already pays for the medical coverage of the uninsured. Because hospitals try to cover reimbursement deficits by raising prices, the overall cost of care for all citizens increases, thereby creating a triple taxpayer burden of additional cost for health care, and additional taxation to support care of those without adequate health insurance, and special subsidies to many of the institutions that are the default providers of care to these patients. The provision of comprehensive trauma care is a noble cause, but must be supported by a financial margin that does not undermine the fiscal solvency of the entire American health care system.

The most significant improvement in the care of injured patients in the United States has occurred through the development of trauma systems.^{24,25,26,27,28} However, recent data show that only 60% of states in the United States have statewide trauma systems, and about 20% have no trauma system at all. The necessary elements of a trauma system are access to care, prehospital care, hospital care, rehabilitation, prevention, disaster medical planning, patient education, research, and accountable financial planning. Prehospital communications, transport system, trained personnel, and qualified trauma care personnel for all phases of care are essential for a system’s success (Fig. 4-1).

External peer review generally is used to verify specific hospital’s capabilities and its ability to deliver the appropriate level of care. The verification process can be accomplished through the ACSCOT or by inviting experts in the field of trauma as outside reviewers. Quality assessment and quality improvement is a vital component of the system, as it provides directions for improvement as well as constant evaluation of the system’s performance and needs.^29,30,31,32

The Model Trauma Care System Plan introduced the concept of the “inclusive system” (Fig. 4-2). Based on this model, trauma centers are identified by their ability to provide definitive care to the most critically injured, and the trauma system assessed by its ability to manage all injuries.^33,34,35 Approximately 15% of all trauma patients will benefit from the resources of a level I or II trauma center. Therefore, it is appropriate to plan and expect an inclusive system to encourage participation and to enhance capabilities of the smaller hospitals. Surgical leadership is of fundamental importance in the development of trauma systems. Trauma systems cannot develop without the commitment of the surgeons of a hospital or community.

Public Information, Education, and Injury Prevention

Death following trauma occurs in a trimodel distribution defined in minutes, hours, and days after injury. Effective trauma programs must also focus on injury prevention, since more than half of the deaths occur within minutes of injury, and will never be addressed by acute care. Because trauma is not considered an important public health problem by the general population, efforts to increase awareness of the public as well as to instruct the public about how the system operates and how to access the system are important and mandatory. A recent Harris Poll conducted by the ATS showed that most citizens value existence of a trauma system with the same importance as fire and police services. Continuous epidemiological surveillance to define interventions that will likely reduce both injury occurrence and severity requires trauma systems to focus on injury prevention. Identification of risk factors and high-risk groups, development of strategies to alter personal behavior through education or legislation, and other preventive measures have the greatest impact on trauma in the community, and, over time, will have the greatest effect on all trauma victims.^18,19,20

Human Resources

Because the system cannot function optimally without qualified personnel, a high quality system provides comprehensive and continuing education to its providers. This includes all personnel along the trauma care continuum: physicians, nurses, EMTs, and others who impact the patient and/or the patient’s family.

Prehospital

Trauma care prior to hospital arrival has a direct effect on survival. The system must ensure prompt access and dispatch of qualified personnel, appropriate care at the scene, and safe and rapid transport of the patient to the closest, most appropriate facility. The primary focus is on education of paramedical personnel to provide initial resuscitation, triage, and treatment of trauma patients. Effective prehospital care requires coordination between various public safety agencies and hospitals to maximize efficiency, minimize duplication of services, and provide care at a reasonable cost. There are many comprehensive and standardized courses covering virtually every aspect of prehospital care. Most are the products of national and international organizations dedicated to emergency medical care, and should be considered as the preferred alternative to “home grown” courses or periodic symposia that provide inconsistent educational impact.

Communications System

A reliable communications system is essential for providing optimal trauma care. Although many urban centers have used modern electronic technology to establish emergency systems, most rural communities have not. A communications system must include universal access to emergency telephone numbers (eg, 911), trained dispatch personnel who can efficiently match EMS expertise with the patient’s needs, and the capability of EMS personnel at the trauma incident to communicate with prehospital dispatch, the trauma hospital, and other units. Access also requires that all users know how to access and actually use the system. This can be achieved through public safety information and school educational programs designed to inform health care providers and the public about emergency medical access.

Medical Direction

Medical direction provides the operational matrix for care provided in the field. It grants freedom of action and limitations to EMTs who must rescue injured patients. The medical director is responsible for the design and implementation of field treatment guidelines, their timely revision, and their quality control. Medical direction can be “off-line” in the form of protocols for training, triage, treatment, transport, and technical skill operations or “online,” given directly to the field provider.

Definitive Care Facilities

Acute care hospitals are the foundation of the regional trauma system. An inclusive trauma system integrates acute care facilities of all levels to provide the full spectrum of injury care within its region. Central to trauma system planning is the designation of definitive trauma care facilities to meet community need. The number and levels of trauma centers should match the population distribution in the region. Trauma centers concentrate rare and high value resources required to optimize care of the injured patient. Concentration of injured patients in trauma centers enhances clinical experience and promotes expertise, education, and research. In principle, the designating authority is responsible for determining the number and level of trauma centers needed to provide optimal care in its region. In practice, trauma centers and acute care hospitals should coexist within a region and cooperate to ensure appropriate distribution of patients based on resource needs, contribute data to trauma system registries, and participate in system performance improvement. A trauma center is an acute care hospital that organizes its available resources around the care of the injured patient. This effort requires the commitment hospital administration and the medical staff to allocate human and material resources and develop performance improvement programs to optimize care of the injured patient. Common to all trauma centers is the trauma program lead by a trauma medical director and a trauma program manager, a trauma registry managed by trained registrars, a comprehensive trauma performance improvement system, and an effective patient safety program. The clinical capabilities and the depth and complexity of resources committed to the trauma program differentiate trauma centers into mission related levels.

Trauma Center Facilities and Leadership

Hospital care of the injured patient requires commitment from specific facilities to provide administrative support, medical staff, nursing staff, and other support personnel. The trauma center integrates into the trauma care system by providing local or regional leadership. Trauma centers are categorized by level, as described below.

Level IV Trauma Center

In principle the level IV center serves as an initial access point to the regional trauma system and usually serves rural communities. The level IV trauma center must have 24-hour emergency coverage and provide initial evaluation and stabilization of injured patients most of whom will be transferred for definitive treatment. Thus the level IV trauma center must have an organized trauma resuscitation team that follows standardized protocols and predefined transfer plans for patients needing a higher level of care.

Level III Trauma Center

The level III center is also an entry point to the regional trauma system usually in communities that are remote from major trauma centers. The presence of general surgery capability differentiates the level III from the level IV center and it is expected that a general surgeon will be present in the emergency department to lead the trauma resuscitation team upon arrival of the major trauma patient. The role of the level III center is to provide definitive care to the mild and moderately injured and initial stabilization for the major trauma patient, which may include operative hemorrhage control to ensure safe transfer to a major trauma center. As with the level IV center, predefined plans for transfer of patients to the major trauma centers are essential.

Level II Trauma Center

The level II provides definitive care to the injured patient, and functions in two distinct roles recognized by the ACS COT. The first is as a facility in a population dense area in which a level II center may supplement the clinical activity and expertise of the regional level I center. In this context, the level I and II centers cooperate to ensure optimal resource utilization. The second is in less populated areas distant from the regional level I center. In this context the level II center may serve as the lead hospital for its region and provide support to local minor trauma centers in the same service area. The level II centers include the specialty services needed to provide definitive care to the severely injured but the clinical capabilities may not be as comprehensive as the level I centers. Although the clinical capabilities are similar to LI, the level II centers may not treat a volume of severely injured patients similar to LI centers. Although graduate education and research are not required functions of level II trauma centers the mandate for similar clinical capabilities requires that LII centers provide effective access to continuing medical education (CME).

Level I Trauma Center

The level I trauma center is a regional resource and tertiary care facility capable of providing immediate definitive and comprehensive care to all injured patients regardless of severity or complexity. It is the cornerstone of the regional trauma system. In addition to comprehensive acute care responsibilities, the level I trauma center has a major responsibility for providing leadership in system planning, research, education, and training of trauma care providers. Level I trauma centers are generally located in large, population dense areas and are typically affiliated with university teaching hospitals. Colocation with a large population and a high volume of severely injured patients is necessary to provide sufficient experience to develop clinical expertise, train new providers, and fulfill the level I research and education missions.

The Trauma Resuscitation Team

In all trauma centers there must be a defined trauma resuscitation team consisting of predesignated personnel and specific assignments. The team’s main purpose is rapid patient assessment, provision of immediately lifesaving interventions, initiation of comprehensive resuscitation, expeditious diagnostic workup, and provision of definitive care. Critical to the resuscitation team’s function is linkage to EMS and timely prehospital notification. For major trauma patients identified in the field, the resuscitation team must be preassembled and immediately available upon patient arrival. The constituents, role, and capabilities of the resuscitation team depend on the level of trauma centers.

Specialty Trauma Centers

Regional specialty facilities concentrate expertise in a specific discipline and serve as a valuable resource for patients with critical specialty-oriented injuries. Examples include replantation, pediatric trauma, bums, spinal cord injuries, and hand trauma. Where present, these facilities provide a valuable resource to the community and should be included in the design of the system. Most importantly, the unique capabilities of each must be seamlessly woven into the process of care so that the required specialty care is available at the appropriate time in the continuum of management of the patient. A pediatric trauma center is expected to have the same resuscitative capabilities as any center receiving acutely injured patients from the field. A replantation or burn center, on the other hand, is usually reliant on comprehensive initial evaluation of the patient by a referring center with whom it must have established transfer guidelines and protocols.

Acute Care Facilities Within the Trauma System

Many general hospitals exist within a trauma care system but are not officially designated as trauma centers. Circumstances often exist in which less severely injured patients reach these hospitals and appropriate care is provided. The trauma system should develop and manage protocols for inter facility transfer of patients whenever a major trauma patient is inappropriately triaged to an undesignated facility. Moreover, the trauma system’s registry must be able to identify and track these injured patients managed at non designated facilities.

All acute care facilities play important roles in the regional trauma system. Most patients have minor injuries and can receive effective and definitive care in acute care hospitals (Fig 4-3). Community hospitals and minor trauma are critical to the care of mild and moderately injured by providing effective treatment to patients in their home communities. This helps minimize the burden on the patient and preserves major trauma center resources for the care of the more seriously injured. However, major trauma centers, especially level I centers are typically large tertiary referral centers located in population dense areas and serve as the primary hospital for their communities. As such, major trauma centers tend to attract a many mild and moderately injured patients simply because of proximity to the population and large market share.³⁵ Effective trauma system planning must recognize this phenomenon to ensure the proper balance of trauma center numbers and levels within a region. Sufficient minor trauma resources should be available to care for the minor and moderately injured and sufficient major trauma center resources to not only ensure access to definitive care for the severely injured, but also concentrate severe injury volume in a limited number of major trauma centers to optimize clinical competency through experience and maximize efficiency through conservation of scarce, high value human and material resources.

Rehabilitation

The disease of injury is described as a continuum of care that begins with failure of prevention and ends with complete societal reintegration of a recovered patient. In reality, injury is a disease that never really ends. The issues of long-term neurocognitive dysfunction and early onset of degenerative disorders is well defined in current literature. Less well understood are the impacts of chronic musculoskeletal disorders, chronic pain affliction, and numerous other impairments that undermine quality of daily living and social function. Rehabilitation is as important as prehospital and acute hospital care. Early and aggressive rehabilitation has been shown both to accelerate and enhance recovery, yet it is often least considered and incompletely available. Many insurance policies do not even cover rehabilitation, leading to a major additional burden for the “insured” patient who discovers that coverage ends with hospital discharge. Although it is critically important to reintegrating the patient into society, only 1 of 10 trauma patients in the United States has access to an adequate rehabilitation program. Rehabilitation is often the longest and most difficult phase of care for both patient and family. It can be provided in a designated area within the trauma center or by agreement with a freestanding rehabilitation center, but it must be provided! While it is not the purpose of this chapter to address all of the deficiencies of the health care system, it is important that trauma system planners understand this deficiency and establish processes that provide immediate involvement of rehabilitation experts as well as case managers to optimize timing and effect of patient rehabilitation, and, from the other side of the coin, limit unnecessary acute care hospitalization necessary because of lack of rehabilitation access. This latter phenomenon is detrimental to optimal recovery, adds additional financial burden to the trauma center, and denies acute care beds to other injury victims.

Emergency Response and Trauma System Access

A critical function of the regional trauma system is to ensure that all injured patients within its geographic boundaries have access to definitive care to meet their injury needs. Access to the trauma system is dependent on the availability of prehospital transport services, the proximity and availability of definitive care resources, and the processes that direct the injured patient to definitive care. Ideally, the geographic distribution of trauma centers matches the population distribution and prehospital resources are organized such that timely access to the trauma center is ensured independent of distance. In 2005, it was estimated that 69.2% of US residents could access a major trauma center within 45 minutes and 84.1% could access one within 60 minutes of injury.³⁶ The remainder lived primarily in rural areas and states with the most urban populations had the highest proportions that could access a trauma center within an hour. More current data estimates that 63.1% of the US population can reach a major trauma center within an hour by ambulance and the inclusion of helicopter services increased this proportion to 90.4%. The University of Pennsylvania, in consort with the American Trauma Society and with support of the US Department of Health and Human Services manages a comprehensive website (http://www.TraumaMaps.org) which is periodically updated and provides a continuous overview of trauma system coverage in the United States.

Prehospital Triage and Transport

Access to trauma care is not only dependent on the availability of EMS and hospital physical resources, but also the processes that govern the delivery of the patient to definitive care. Triage is the process by which injured patients are sorted to ensure that each has timely access to the appropriate level of care based on medical need and availability of resources. A critical function of the regional trauma system is to triage major trauma patients to major trauma centers. This often requires bypass of a closer hospital in favor of a trauma center for major trauma patients. Triage should be selective so that medical resources are allocated to the patients that will realize the most benefit. Triage is a dynamic process that occurs continually at every phase of patient contact. Initial triage decisions are often revised as more information becomes available. Triage priorities may also be modified based on the balance between demand and availability of medical resources as in mass casualty scenarios.

Defining the major trauma patient

There is no standard that defines the major trauma patient. In practice, identification of the major trauma patient depends on the clinical context where differentiation is needed. In the prehospital setting differentiation is needed to determine which patients should be transported directly to the trauma center and is often based on physiologic, mechanism, and patient factors. In the acute care setting differentiation must identify the population that falls within the trauma program’s scope of practice. This may be based on injury pattern, use of specialized resources, or standardized registry inclusion criteria. Retrospective differentiation is necessary to assess trauma system performance and is often based on a mortality prediction thresholds derived from discharge diagnoses and often from secondary data sources. The major trauma patient is defined differently in each context which can make generalizations beyond a specific context problematic. What is apparent acutely in the field and what has been determined by discharge can be very different.

Prehospital Identification of The Major Trauma Patient Using Limited Information

The challenge of trauma triage is to anticipate definitive care needs using limited information available at the time when triage decisions must be made. Of all trauma patients, only 7–15% have injuries that will require the resources of a major trauma center. Although clinical recognition of the major trauma patient is usually straightforward, serious, even life threatening, injuries are sometimes occult and not discovered until after a comprehensive work up. Because mistriage is inherent, triage must be viewed as a continuous, flexible, and error tolerant process with contingencies for mistriage.

Definitions

Primary (Field) Triage

Primary or field triage directs transport from the scene to the highest level of care within a reasonable transport distance for major trauma patients. This usually enables rapid transport directly to major trauma centers in urban and suburban environments. Because the extent of injury is not always evident in the field, prehospital triage guidelines are established to identify patients at risk for severe injury and aid prehospital decision making. These tools are designed to be simple and applied broadly; the main purpose is to determine if the patient’s estimated risk warrants transport to the nearest major trauma center rather than the nearest hospital. Risk of severe injury is estimated using information based on physical examination, mechanism characteristics, and pre-injury patient characteristics easily obtained by EMS on initial patient contact. Criteria for field triage are ordered with physiologic derangements indicating highest risk followed by anatomic findings, energy transfer mechanisms, and pre-injury patient comorbidities in decreasing order.

Brief Review Of Methods Proposed for Field Triage Scoring

To be useful in the field, a triage protocol must meet certain criteria.³⁷ The components of the scoring scheme must be credible, and have some correlation with the injuries being encountered. The triage scoring method must correlate with outcome, although its primary purpose is identification of immediate patient risk. The better the correlation with outcome, the lower the undertriage and overtriage rates within a trauma care system. Outcomes for major trauma victims are usually classified as death, need for urgent/emergent surgical intervention, length of intensive care unit (ICU) and/or hospital stay, and major single-system or multisystem organ injuries.

The scoring scheme must also have interobserver and intraobserver reliability, that is, it should be able to be consistently applied between observers and by the same observer at another point in time with the same results, recognizing that the patient may have changed as a result of injury or therapy over time. Finally, the scoring scheme must be practical and easily applied to trauma victims for a variety of mechanisms, by a variety of personnel without the need of specialized training or equipment.

While most of the field triage criteria are based on physiologic criteria, there are other methods for assessing the severity of the potential injury to a trauma victim. As shown earlier in the chapter, mechanism of injury, anatomic region and type of injury, preexisting illnesses, and paramedic judgment are important considerations in providing additional information in the field to help determine whether a patient requires transport to a designated trauma center. Combination field triage methods make use of this additional information by including it in the initial evaluation of the trauma victim. As trauma systems have evolved, the determination of which variables are most effective in attaining the accuracy required for optimal system function has resulted in numerous proposed methods. Table 4-3 lists a brief history of some of these approaches. All were designed to assist rescue personnel in determining which patient required transport to a trauma center.^{38,39,40,41,42,43,44} The Pediatric Trauma Score (PTS) is the only one developed specifically for assessment of children.⁴⁵ As the work detailed in Table 4-3 developed, the ACSCOT, in collaboration with the CDC compiled all of this experience into a single process and developed the ACS Field Triage System. This is a more complete, advanced triage scoring scheme that is described in the Resources for Optimal Care of the Injured Patient, and reflects years of productive collaboration with the CDC.

Current Triage Recommendations

Since 1986, the ACSCOT has provided guidance for the field triage process through its “Field Triage Decision Scheme.” This guidance was periodically updated in 1986, 1990, 1993, and 1999. In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACSCOT to convene the initial meetings of the National Expert Panel on Field Triage to revise the decision scheme, which was published in 2006 by ACSCOT as part of Resources for the Optimal Care of the Injured Patient: 2006. In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria R2t. CDC reconvened the Panel in 2011 to review the 2006 guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the guidelines, and recommend any modifications to these guidelines.⁶⁰

As has been the case from the beginning, the intent of these triage guidelines is to assist prehospital care providers in determination individual injured patients who would benefit from specialized trauma center resources. The process is designed to guide assessment of an individual patient and is not intended as a triage tool to be used in a situation involving mass casualties or disaster. Based on the extensive history of critical thinking, evaluation, review and revision detailed above, the current recommended process of assessment proceeds in four phases (Fig. 4-4).

Step One: Physiologic Criteria

The first step is rapid identification of critically injured patients by assessing level of consciousness (Glasgow Coma Scale [GCS]) and measuring vital signs (systolic blood pressure [SBP] and respiratory rate). Vital sign criteria have been used since the 1987 version of the ACS Field Triage Decision Protocol. These criteria demonstrate high predictive value for severe injury. Of 289 references identified from the CDC panel’s structured literature review, 82 (28%) were relevant to Step One. SBP less than 90 and respiratory rate less than 10 or greater than 29 remain significant predictors of severe injury and the need for a high level of trauma care. Multiple peer-reviewed articles published since 2006 support this threshold.

Recommended criteria for transport the highest level of care are

• Glasgow Coma Scale less than or equal to 13

• SBP of less than 90 mm Hg

• Respiratory rate of less than 10 or greater than 29 breaths per minute (<20 in infant aged <1 year), or need for ventilatory support

Step Two: Anatomic Criteria

The second step considers that certain patients may initially manifest normal physiology but have an anatomic injury at risk of rapid deterioration and therefore may require the highest level of care. Of the 289 references reviewed by the panel, 57 (20%) were relevant to step two.

Current recommendations for transport to a facility that provides the highest level of care include

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee

• Chest wall instability or deformity (eg, flail chest)

• Two or more proximal long-bone fractures

• Crushed, degloved, mangled, or pulseless extremity

• Amputation proximal to wrist or ankle

• Pelvic fractures

• Open or depressed skull fractures

• Paralysis

Step Three: Mechanism of Injury

Step three addresses mechanism of injury from the perspective of assessment of magnitude and vectors of force. An injured patient who does not meet step one or step two criteria should be evaluated in terms of mechanism of injury (MOI) to determine the potential for severe but occult injury. Evaluation of MOI will help to determine if the patient should be transported to a trauma center.

Step Four: Special Considerations

In the fourth step, EMS personnel must determine whether persons who have not met physiologic, anatomic, or mechanism steps have underlying conditions or comorbid factors that place them at higher risk of injury or that aid in identifying the seriously injured patient. Persons who meet step four criteria might require trauma center care. A retrospective study of approximately one million trauma patients indicated that using physiologic (step one) and anatomic (step two) criteria alone for triage of patients resulted in a high degree of under triage, implying that using special considerations for determining trauma center need helped reduce the problem of under triage.⁴⁶ Among 89,441 injured patients evaluated by EMS providers at six sites, physiologic, anatomic, and mechanism of injury criteria identified 4049 (70.8%) patients with an ISS greater than 15; step four of the guidelines identified another 956 (16.7%) of seriously injured patients, with increase in overtriage from 25.3% to 37.3%.⁶⁰

“Internal” triage and the trauma resuscitation team

The hospital response to prehospital notification is tiered to match the initially assessed level of need. Most severely injured patients require full team activation with all members, including surgeons, immediately responding. Less severely injured may need a partial resuscitation team response, while other patients may be transported to trauma center, evaluated by an emergency physician, and the resuscitation team or other specialty services consulted as needed. The overarching factor governing this process is patient need. It must be counterbalanced, however by the fact that unnecessary mobilization of expensive resources robs them from other critical missions and is often unnecessarily wasteful.⁶¹ Thus, the process of internal triage is predicated on how well a trauma center can balance its extensive and expensive resources against patient need and logistical reality. The process may vary among centers and reflect unique capabilities or services available at different institutions. The most recent edition of the Resources for the Optimal Care of the Injured Patient: 2006 includes ACSCOT recommendations regarding major resuscitation criteria. Regardless of how the internal triage process is developed, it must be data driven, continuously assessed and support the overall effectiveness of the trauma system.

Secondary (interfacility) triage

Secondary or interfacility triage directs transfer of patients whose needs exceed the capabilities of the initial receiving facility to a higher level for definitive care. This commonly occurs when patients who do not meet primary triage criteria are transported to a minor trauma center or community hospital and are subsequently found to have injuries are beyond the capabilities of the initial receiving facility.^62,63 In remote or rural environments, secondary triage serves to connect minor trauma centers to the major trauma centers after providing initial evaluation and stabilization of the major trauma patient. Like the field triage guidelines, interfacility (secondary) transfer guidelines aim to identify patients at high risk of morbidity or mortality based on injury patterns who might benefit from treatment at a trauma center and recommend early transfer. Occasionally, patients that meet neither field triage nor secondary transfer guidelines are found to have injuries that exceed the capabilities of the initial treating facility. The Emergency Medical Treatment and Labor Act (EMTALA) intends that such patients have access to a higher level of care.

Measuring Triage Accuracy

The regional trauma system’s ability to deliver the right patient to the right place at the right time and make the best use of available resources is expressed as triage accuracy.⁶⁴ Mistriage (overtriage and undertriage) occurs when a patient triage decisions are not commensurate with their clinical needs. Triage accuracy is dependent on compliance with established triage tools and the ability of those tools to predict the outcome of interest. Since triage is a continuous, dynamic process, opportunities for mistriage can occur during any phase of injury care. Field triage destination decisions are made using the best information available at the time. Inhospital triage and trauma resuscitation team activation decisions are made using the information provided from the field. Secondary triage and interfacility transfer decisions are made with more complete information but are influenced by the availability of resources at the referring facility. At any point, early decisions may appear to have been incorrect once more information is obtained. Consequently retrospective evaluation of early decisions, using more information than was available at the time, introduces inherent methodological mistriage. This error is worsened when real-time time identification of a major trauma patient using a field triage tools is evaluated using a different retrospective definition of a major trauma patient based on another system such as injury severity scoring or a mortality prediction model. Thus what looks like mistriage in part maybe the combined effects of the retrospective evaluation of real-time decisions using disparate definitions.

Overtriage is a triage decision that incorrectly classifies a patient as needing a trauma center but retrospective analysis suggests that such care was not needed, and undertriage is a triage decision that classifies a patients as not needing trauma center when, in fact, they do. While intuitive, operationalizing these definitions into objective quality metrics is problematic. There is no retrospective standard that defines which patients need trauma centers, and which do not. The term “severe injury” is commonly used to refer to patients that need trauma centers and is often applied based on meeting an injury severity score or mortality prediction threshold or consuming specific hospital resources such as operative or ICU care. This assumes that all patients and only patients that meet these definitions require trauma center care. In reality, there are many patients that do not meet such definitions but need major trauma center care, typically because definitive care resources may not be available in the community. Likewise, there are many patients who meet these definitions that may receive high quality injury care at in minor trauma centers or community hospitals.

Equivocation of terms when expressing over or under triage rates also complicates trauma systems research. For example, the field undertriage rate could be expressed as the number of major trauma patients that did not receive the highest level of trauma team activation relative to the total number of trauma team activations. It could also be expressed relative to the total number of major trauma patients or relative to the total number of all injured patients. Each conveys important but different information; the first reflects the proportion of trauma team activations that were under triaged, the second the proportion of major trauma patients that were under triaged, and the last the proportion of all patients that were under triaged. The same issues occur with equivocation of overtriage terms. The need to differentiate field triage, which reflects primary destination decisions, and system triage, which reflects the final patient distribution within the system further complicates terms since over and under triage occurs at both the field and system levels.

An approach to minimize equivocation of terms is to apply standard contingency table terminology to both field and system triage (Table 4-4). Given that triage accuracy is the number of patients appropriately triaged relative to the total number of patients, then inaccuracy or mistriage is the number of inappropriately triaged patients relative to the total. Since mistriage is a reflection of both over and under triage, then 1 = accuracy + overtriage + undertriage. Here accuracy, overtriage, and undertriage have precise meanings at both the field and system levels. Sensitivity, specificity and positive and negative predictive values convey meaningful information at the field level since field triage is expected predict major trauma but less so at the system level the distribution of low and high risk patients between major trauma centers and other hospitals is described. Utilization refers to the proportions of low- and high-risk patients discharged from major trauma centers and other hospitals.

The study of triage accuracy is conceptually, linguistically, and technically complex. Together field triage, secondary transfer, and EMTALA regulations, and the role of major trauma centers as large community hospitals influence access to resources in the regional trauma system. Application of these regulations and the hospital capabilities determine the final distribution of injured patients. Inherent methodological errors introduced by retrospective evaluation of treatment decisions, equivocation of terms, and generalizations between phases of triage must be taken into account when making conclusions on overall triage performance and setting system triage benchmarks.

Disaster Management

Terrorism is the emerging weapon of modern civil strife. Terrorism events now occur almost weekly in various countries around the world, and are usually designed to inflict as much damage as possible to innocent bystanders and then to strike again when rescuers arrive. Manmade events such as these and natural disasters such as Katrina (New Orleans), Superstorm Sandy (New Jersey and New York), and the endless stream of floods and devastating tornados that seem to increase in frequency with every passing year should crystallize the resolve of all medical personnel to become educated and proficient in disaster management. The approach to disasters, whether natural or manmade, requires a coordinated relief effort of EMS, hospital, fire, police, public works personnel, and often the military. This multiorganizational operation can effectively manage a crisis only if it is well directed and controlled. The ability to assess a disaster scene, summon appropriate personnel to provide damage control, fire management, rescue operations, and crowd control is dependent on an organization structure that permits dynamic information processing and decision making based on adequate planning and accurate vital scene information.

The military uses the concept of command and control for its combat operations. Key personnel continually monitor and manage the battlefield situation. The Fire Service of the US Department of Forestry, in 1970, adapted command and control into an incident command structure. Within this framework, a centralized group of disaster personnel commands and controls all of resources at the disaster site. Dynamic disaster scene information is processed at a predesignated incident command center where decisions regarding deployment and mission of rescue resources are implemented.

The incident command center structure is composed of seven key groups. If the disaster is small in scope, a single person may fill all seven areas. As the disaster increases in scope, more personnel are required to fulfill these functions. The incident commander is responsible for the entire rescue or recovery operation. Under the direction of the incident commander are the seven group commanders: operations, logistics, planning, finance, safety, information, and liaison. Each of these section commanders has well-defined areas of authority and responsibility. Continuous on-scene information will be communicated to the command center. This will enable the incident command center to plan and direct the rescue or recovery operation. Thus, limited resources and key personnel will be directed to produce the greatest benefit.

The disaster scene is typically divided into zones of operation. Ground zero is the inner hazard zone where the fire and rescue operations occur. EMS and other nonessential personnel are kept out of this area. Rescued victims are brought out of this area to the EMS staging area. This is the second zone, a primary casualty receiving area, and it is here that EMS personnel perform triage and initial care for the patient. Disposition directly to the hospital may occur or the patient may be sent to a distant receiving area for care and ultimate triage and transport.

The distant casualty receiving areas provide for additional safety in the environment. This downstream movement of injured patients prevents the primary triage sites from being overrun. Transportation of the wounded from the primary receiving site is reserved for the most seriously injured patients. Thus, a tiered triage approach is developed. A temporary morgue is also set up at a distant site.

Typically, groups of patients, the walking wounded, will migrate toward the nearest medical treatment facility. This process is called convergence. Medical facilities often set up a triage area in front of the emergency department to handle these patients. Current medical philosophy and federal regulations mandate treatment of any patient who arrives at an institution’s emergency department. In mass casualty situations, however this can quickly overwhelm facility function and actually diminish effectiveness of care for all patients. Appropriate community disaster planning must recognize this potential problem and establish processes to direct certain groups of these patients to secondary medical facilities. The use of outpatient surgery centers, which are proliferating throughout the country may be a valuable resource for this purpose. The final operational zone of the disaster site is the outer perimeter. Police permit only essential personnel access into the disaster site. Crowd and traffic control ensure the safety and security of the disaster scene as well as to provide emergency vehicles rapid transit to and from the site.

Disasters may be of a small scale such as a building fire or explosion and may remain only a local or regional problem. As was demonstrated in the wake of the World Trade Center attack and Superstorm Sandy, the magnitude of a local disaster was of such proportions that activation of the National Disaster Medical System was necessary to address the rescue and recovery efforts. Analysis of more recent natural disasters demonstrates that approximately 10–15% of the survivors were seriously injured. The remaining victims either were dead or had mild to moderate trauma. Thus, overall effectiveness of disaster response is predicated on rapid sorting of survivors to determine the level of care needed by each patient.

In managing the World Trade Center attack, the New York Fire Department and EMS utilized the START system. The initial scene casualties were from the planes striking the building. Fire and rescue personnel could not reach these patients. With the collapse of the first tower, rescue operations were aborted and attempts to evacuate rescue personnel became paramount.⁶⁵ After the building collapsed, victims injured in the street or from the surrounding buildings required medical treatment. As rescue operations resumed, injured rescue workers began to arrive at medical treatment facilities. Unfortunately, there were only five survivors of the Twin Tower collapse with over 3000 fatalities, which included civilians and rescue personnel.

Israel’s experience with terrorist attacks has demonstrated that rapid and accurate triage is critical to decrease or minimize mortality. Therefore, it has been suggested that the best triage officer, at least in bombings and shooting massacres, which are the most common form of terrorist violence, is the trauma surgeon. This is important to guarantee that those in real need of immediate surgical attention are seen and treated in a timely fashion without inundating the hospitals with patients who can be treated at a later time.

Many critical concepts have been learned from the Israeli experience. These include rapid and abbreviated care, unidirectional flow of casualties, minimization of the use of diagnostic tests, and relief of medical teams every so often to maintain quality and effectiveness in care delivery. The concepts of damage control should be liberally applied in the operating room (OR) to free up resources for the next “wave” of injured individuals.^66,67,68,69 During mass casualty events, hospitals become overwhelmed very easily. Therefore, communication between hospitals is critical to distribute the casualties evenly. All surgeons should be familiar with the basic principles of mass casualty management, and trauma surgeons should be the leaders in this field, since trauma systems serve as a template for the triage, evacuation, and treatment of mass casualty victims.⁷⁰

Application of Triage Principles for Multiple Patient Victim Events

Identification of the degree of injury severity that will determine need for transport to a trauma center is the core mission of every triage protocol ever devised. When there are hundreds of patients, however, a completely different process of patient assessment must be deployed. Triaging a single trauma victim is relatively straightforward as described previously. For multiple casualty incidents, such as seen with multiple cars involved in a large scale crash, the same essential principles apply; however, decisions must be made in the field as to which patients have priority. A multiple casualty incident (MCI) can be defined as any situation where the volume of patients with injury severity may exceed hospital resources. Patients who are identified as major trauma victims by field triage criteria have priority over those who appear less injured. All major trauma patients should be transported to a trauma center as long as the trauma center has adequate resources to manage all the patients effectively. Because this situation can stress local resources, a properly conceived regional or state disaster management plan should include provision for possible diversion of the less critically injured to another trauma center or appropriately equipped hospital. Monitoring transports with online computer assistance allows for contemporaneous determination if one trauma center is overwhelmed.

Mass Casualties

Triage in this situation is unique in that priorities are different from those in the single- or multiple-victim scenarios. In the instance of mass casualties, the resources of the designated trauma center, as well as the regional trauma system, are overwhelmed. When resources are inadequate to meet the needs of all the victims, priority shifts from providing care to those with the most urgent need to providing care to those with the highest probability of survival. A severely injured patient, who would consume a large amount of medical resources, is now a lower triage priority. Despite the potential salvageability of this patient, the medical resources are focused on other patients who would benefit from advanced medical and surgical care. This method provides the greatest good for the greatest number of people. Field triage in this situation is probably the most difficult to perform as one has to make choices of quantity over quality with very limited amounts of information. These issues are further complicated when dealing with children.⁷¹

The most experienced and best-trained personnel available should make these field triage decisions. Physicians may be the best qualified to make these triage decisions; however, if they are the only receiving physicians available, direct patient care should take precedence and triage decisions would fall to other personnel. Patients are identified according to a triage code, based on the severity of injuries and likelihood of survival, and are treated accordingly. Occasionally, there may be an indication for a specialized surgical triage team with the capability to render acute lifesaving care of an injured trapped patient.⁷² In some disaster scenarios moving intensive care capabilities into a disaster zone may be beneficial when evacuation of patients may be unrealistic due to logistical reasons.

In order to optimize patient care in these situations, it is important for regionalized systems to stage periodic mock disaster drills. These drills allow for the proper training of all individuals who might be involved as well as the identification and correction of potential problems. With increasing terrorist activity, specific triage algorithms have been developed for specific scenarios such as biologic, chemical, radiologic, or blast attacks.⁷³

Disaster Triage: Simple Triage and Rapid Treatment

In the event of a mass casualty or disaster, EMS personnel may utilize the simple triage and rapid treatment (START) triage system initially developed to be used in earthquakes in California. The object of this system is to triage large numbers of patients rapidly. It is relatively simple and can be used with limited training.⁷⁴ The focus of START is to evaluate four physiologic variables: the patient’s ability to ambulate, respiratory function, systemic perfusion, and level of consciousness. It can be performed by lay and emergency personnel. Victims are usually divided into one of the four groups with color codes according to the timing of care delivery based on the clinical evaluation as follows: (1) green—minor injuries (walking wounded); (2) red—immediate; (3) yellow—delayed; and (4) black—unsalvageable or deceased.

If the patient is able to walk, he or she is classified as a delayed transport, but if not, ventilation is assessed. If the respiratory rate is greater than 30, the patient is an immediate transport. If the respiratory rate is less than 30, perfusion is assessed. A capillary refill of greater than 2 seconds will mandate an immediate transport. If the capillary refill is less than 2 seconds, the patient’s level of consciousness is assessed. If the patient cannot follow commands, he or she is immediately transported; otherwise he or she is a delayed transport. In light of the concerns about the predictive accuracy of capillary refill, some systems link the START method with severity scores: in the immediate category the Revised Trauma Score varies from 3 to 10, in the urgent category it varies from 10 to 11, and in the delayed (nonurgent) group the RTS is 12. Mass casualty triage principles are the same for children and adults. However, differences in physiology, response to physiologic insult, ability to talk and walk, and anatomic characteristics, disaster triage in the pediatric age group is not as straightforward. Whenever possible, decisions regarding disposition of children should include consideration of availability of parental support.

A major benefit of the START system is accurate identification of severely injured trauma patients who may be able to be transported by air or ground ambulances to more distant trauma centers where the lower number of victims will assure that resources are available to provide optimal care.

Overview

As stated at the beginning of this chapter, trauma system sustainability is based on accountability. Accountability is phrased first in optimal outcome for every injury victim. Concurrent with this goal is confirmation of optimally achievable cost efficiency in delivering this care and ameliorating the financial burden of injury on the population. This process of accountability must also be able to support adequate analytics to define and deploy best practice. To achieve this goal, reliable system-wide data collection and analysis is an absolute necessity. Accurate, objective, and relevant data are the glue that keeps the trauma system functioning and the fuel that drives its continuous improvement.^{29,30,31,32,75,76} A statewide trauma registry is necessary to assure commonality of critical data terminology, however, as the proliferation of electronic medical records continues to transform the clinical data ecosystem, adequate connectivity and interoperability of multiple data sources will be necessary to ensure that the trauma system is a self-learning, data driven process of continuous quality improvement. Information from each phase of care is important and must be linked with every other phase. This level of data compatibility from different phases of care is especially important to determine the effects of certain interventions on long-term outcome. Constant system evaluation is necessary to identify where the system falls short operationally and stimulate strategies for improvements in system design.^77,78 This feedback mechanism must be part of the system plan for evaluation, and must include designation of the agencies that will be responsible for data system management, definition of accountability metrics, and determination of best practice. Because each of these, and many subcomponents thereof may fall within the purview of different stakeholder groups, and may require special data security arrangements, this process should be defined as part of the regional trauma system plan. The American College of Surgeons Committee on Trauma has developed multiple programs and quality assessment processes that can guide this program as well as provide objective external review.⁴

Analysis of Trauma System Performance

The data on trauma system effectiveness published in the literature are difficult to interpret due to great variability in study design, type of analysis, and definition of outcome variables. Different study designs have been used to evaluate trauma system effectiveness. The most common scientific approaches include panel review of preventable death studies, trauma registry performance comparisons, and population-based studies. Panel review studies are conducted by experts who review trauma-related deaths to determine preventability. Well-defined criteria and standardized definitions regarding preventability have been used, but significant methodological problems can lead to inconsistencies in the results and interpretation of the data.^21,29,79 Celso’s meta-analysis of trauma system assessment provides an extensive review of various methods applied to the processes of assessment of the function and effect of trauma systems.⁸⁰

In an attempt to review the existing evidence on the effectiveness of trauma systems, the Oregon Health Sciences University with support from the NTHSA and the National Center for Injury Prevention and Control of the CDC organized the Academic Symposium to Evaluate Evidence Regarding the Efficacy of Trauma Systems, also known as the Skamania Symposium.²² Trauma care providers, policy makers, administrators, and researchers reviewed and discussed the available literature in an attempt to determine the impact of trauma systems on quality of patient care. The available literature on trauma system effectiveness does not contain class I (prospective randomized controlled trials) or class II studies (well-designed, prospective or retrospective controlled cohort studies, or case-controlled studies). There are several class III (panel studies, case series, or registry based) studies that were reviewed and discussed during the symposium. According to Mann et al, review of the published literature in preparation for the Skamania Symposium supported the conclusion that the implementation of trauma systems decreases hospital mortality of severely injured patients.²⁸ Independent of the methodology used (panel review, registry based, or population based), and despite the above-mentioned limitations of each study design, a decrease in mortality of 15–20% has been shown with the implementation of trauma systems.^26,81 This has been most recently determined in analysis of the impact of the first 5 years of function of the Arkansas trauma system. Mortality decreased as seen in other regions, and inpatient preventable mortality decreased significantly. The leaders of this system are currently evaluating the cost savings generated by the system’s ability to triage the most severe patient to the most appropriate center. The participants of the Skamania symposium also emphasized that not only mortality but also functional outcomes, financial outcomes, patient satisfaction, and cost-effectiveness should be evaluated in future prospective, well-controlled studies.²⁸

Registry studies are frequently used to compare data from an individual trauma center, a trauma system against a national reference norm, between trauma centers within the same system, or at the same trauma center during different periods. The Major Trauma Outcome Study (MTOS) was among the first used as the national reference, although several of its limitations compromise the reliability of the comparison with data from other systems or centers.⁸² Currently the National Trauma Data Bank and the more rigidly controlled datasets supporting the Trauma Quality Improvement Program (TQIP) are available for benchmark analysis. The advantages of registry-based studies include a detailed description of injury severity and physiologic data acquired by trained registrars. The disadvantages are related to inconsistency of data submission, and the need to account for missing data using imputation and often propensity scoring in many multi-institutional analyses.

Population-based studies use information obtained from death certificates, hospital discharge claim data, or fatal accident reporting system (FARS) on all injured patients in a region. These methods of data collection and analysis are important to evaluate changes in outcome before and after, or at different time periods following the implementation of trauma systems in a defined region. Because this is administrative and/or claims related information there is little or no information on physiologic data, injury severity, and treatment. The limitations of the most commonly used databases in population-based studies are described in Table 4-5.

Despite differing approaches to study design one area of rising interest has been comparison of outcomes of inclusive and exclusive systems. As described previously, in an inclusive system, care is provided to all injured patients and involves all acute care facilities, whereas in exclusive systems specialized trauma care is provided only in high-level trauma centers that deliver definitive care. In inclusive systems, patients may be transferred to a higher level of care (trauma center) after initial stabilization based on the availability of resources and expertise in the initial treating facility. Two associated variables can affect overall inclusive trauma system performance: (1) delay in transfer and (2) dilution of trauma centers’ experience. Utter et al. have recently investigated whether mortality is lower in inclusive systems compared to exclusive systems. They concluded that severely injured patients are more likely to survive in states with the most inclusive trauma system, independent of the triage system in place. A possible explanation for these findings includes better initial care in referring hospitals.³³ A more recent study confirms a mortality reduction of 25% in patients under the age of 55.²⁴

One of the benefits of continued analysis of trauma system function has been the identification of specific areas of injury where significant improvements in care and outcomes have emerged by evaluation of similar cohorts of patients across multiple institutions. Major advances have occurred in management of traumatic brain injury, including the benefit of high volume experience in terms of patient survival and quality of recovery.⁸³ Continuous analysis of trauma center data aggregated at the state level affirms the importance of adequate clinical experience to optimize chances for good outcome. Racial and social disparity studies have defined specific issues that directly impact outcomes in these populations, and more importantly document no discriminatory barrier to trauma system access.⁸⁴ Conversely, system assessment clearly underscores the importance of accurate triage and affirms that excessive overtriage makes treatment of minor injury inappropriately expensive and potentially disruptive of the process of care for more severely injured patients.

The greatest modern challenge for which careful system performance monitoring will be critical is management of the elderly. As the American population ages the proportion of patients over 65 years who sustain significant injury continues to increase. These individuals represent a small volume of the overall trauma patient population, yet generate a disproportionate share of the cost of care.^85,86 In addition to disproportionate cost, multiple other factors influence how an effective trauma system must adjust to optimize care for the injured elderly. Despite being more active than their predecessors, most of these patients are afflicted with the usual comorbid conditions associated with aging. The most common mechanism of injury is falls, usually in the home environment. Next most frequent are motor vehicle crashes. The desire to be treated by the physicians or health system with which they are familiar often results in inappropriate triage. Inability to determine whether the patient is at risk because of being injured and elderly versus elderly and acutely injured often results in delayed management of injuries or incomplete assessment deteriorating chronic comorbid conditions. Of even greater importance than simple survival is quality of life post recovery. Transformation of a reasonably healthy, active senior citizen to an impaired dependent is yet another burden of the disease of injury, and demands careful planning, comprehensive case management and compassionate counseling of victims and their families.

Practical Considerations in Trauma System Performance Monitoring

As is apparent in the review of the evolution of trauma systems the major driver of this process has been commitment to eliminate preventable death. Because any injury represents a failure of prevention, the scope of effort has broadened to the concept of an inclusive trauma system that enhances prevention education and integrates all resources into a population based, coordinated enterprise. The milestones of this evolution have been defined by a constant focus on clinical outcomes; what works, what doesn’t, and what needs to be improved. This culture of outcome oriented performance improvement has become the model for similar efforts across all aspects of American health care. The process of quality assessment is well defined elsewhere in this text, however, from a trauma system’s standpoint, the following factors represent the core of what is required for accurate assessment and accountability. As the American health care system continues its transformation and as the clinical data ecosystem evolves to a level that supports the full gamut of health care delivery, system performance and clinical outcome measurement will drive better patient care, more efficiency, and improved population wellness. The following items are some of the major factors which will be measured and will drive continuous quality improvement for the entire trauma system.

The three major domains of trauma system function are

• Clinical effectiveness in reduction of the burden of injury

• Efficient use of resources

• Disaster response infrastructure

Clinical effectiveness is not simply stated in terms of decreased mortality. It must reflect continued focus on elimination of preventable death and optimization of potential recovery for all injury victims. This includes effective prevention of any injury, expeditious care for those at risk, and comprehensive long-term support through full reintegration into society. Trauma system function is predicated on the availability of extensive and expensive resources. These must be used in a cost-efficient and efficacious manner. Processes to measure this and provide objective accountability to society for its investment in citizens’ safety is critical to assure sustainability of the trauma system. Just as the commitment to quality and optimal patient care forged by trauma systems has become a model for clinical care in general, so also has the trauma system collaborative infrastructure that coordinates availability and deployment of critical resources from disparate emerged as the infrastructure that will support effective disaster response.

The Donabedian model of performance assessment defines the items below as the critical factors necessary to address the statements above in a manner that defines trends and identifies opportunities for system improvement. Table 4-6 identifies multiple aspects of trauma system function and theoretical metrics that could be developed to generate a data driven, objective process for continuous performance improvement. The list is by no means complete and is provided as a starting point for thought and as a framework for transformation of relevant questions into objective milestones of success.

Special Problems

An effectively functioning trauma system is a physiologic, sociologic, financial, political, psychological and cultural entity that is in continuous flux. It is an identifiable social commitment by a population to the welfare of all of its citizens. It is an investment of enormous expense in talent and treasure that must be continuously monitored to ensure full accountability for every aspect of its mission.⁸⁷ This chapter has reviewed the evolution of this fascinating and critical health care phenomenon, and described the features that are necessary for implementation and deployment of an effective system. The two final characteristics that define every trauma system’s pathway to survival and success are sustainability and agility. A trauma system will be sustainable if it continues to preserve lives and diminish the burden of injury in terms of cost, lost productivity, and avoidable misery. A trauma system’s agility in managing all of its constituent components to anticipate and preemptively adjust to new challenges in the American economy and health care system is essential for its sustainability. Many changes are fast approaching. The aging population is changing not only patient need, but also the epidemiology of injury. Violence remains a major problem in our culture; however the impact of effective secondary prevention by better focus on environmental safety has diminished the incidence devastating injuries related to high energy transfer. Finally, our population continues to shift, and with it the burden of effective disease control can quickly exceed resources available. The tax base that shifts with this migration is often inadequate to support expansion of the infrastructure required to provide increased coverage. Thus, it is imperative that a trauma system be recognized as a living human endeavor under constant scrutiny to assure optimal return on investment by continuously responding to its population’s needs. It is the quintessential example of a self-learning health system.