Clinical and Health Affairs
Raising the Bar for Trauma Care in Minnesota: Proposal for a Statewide Trauma System
By David M. Larson, M.D., and Tim Held
Abstract
Minnesota is 1 of 9 states in the nation that have not implemented a formal system to coordinate the care that hospitals provide to victims of trauma. Past efforts to initiate such a system have floundered in part because they failed to consider the unique needs and capabilities of rural hospitals, which often are the first providers of care for trauma victims. This article describes a new effort to develop a statewide trauma system. The proposed system attempts to include all hospitals in the state in a voluntary network of trauma care. Key components of the plan include educating staff at small rural hospitals, instituting performance improvement programs, and establishing a trauma registry that will allow for statewide injury analysis.
Trauma is a major health care issue for Minnesotans. According to Minnesota Department of Health statistics, trauma is the leading cause of death for people ages 1 to 44; and more than 2,300 Minnesotans die from trauma each year on average. In addition, for every death, more than 13 people are hospitalized for trauma- related injuries. Motor vehicle crashes are the leading cause of trauma deaths in Minnesota, and 70 percent of the motor vehicle–related fatalities occur in rural Minnesota. Yet, Minnesota is 1 of only 9 states that currently do not have a formal trauma system.1 North Dakota implemented a state trauma system in 1993, Iowa did so in 2001, and Wisconsin is in the final steps of development and implementation of a state trauma system. For many years, a small number of Minnesota hospitals have voluntarily maintained Level I or Level II trauma center verification through the American College of Surgeons (ACS). Even though the state does not recognize, coordinate, or define those facilities as trauma centers, these individual institutions have produced pockets of excellence in trauma care and prevention in Minnesota. Nevertheless, throughout the state there are many areas where citizens are isolated from these resources.
During the past 30 years, the federal government has issued grants to states to develop and implement state trauma systems. The last major federal effort in Minnesota was funded from 1992 through 1994. These initiatives failed to attract serious legislative backing largely because they lacked a broad base of support. Most important was the fact that Minnesota’s rural trauma care providers were not involved in planning the system. Early plans focused on quickly moving the critically injured patient (within the “golden hour”) to large trauma centers in metro areas. It was felt that rapid transport to these facilities offered the best outcomes for critically injured patients because these centers are equipped with advanced technology and highly trained surgical specialists. This exclusive approach to the trauma system, though consistent with national trends, failed to address the needs of rural trauma care providers who remain the key link in evaluating and stabilizing many trauma patients before transfer.
In Minnesota, advocates of a statewide trauma system have since taken note of states that have developed trauma systems that include rural hospitals (eg, Iowa and North Dakota). Two essentials of these trauma systems are provider education and in-house processes for evaluating and enhancing care. Since Minnesota’s early attempts to develop a coordinated trauma system, a growing number ACS-verified trauma centers and other mature statewide trauma systems have emphasized the importance of performance improvement. In 2003, the Society of Trauma Nurses produced its Trauma Outcomes and Performance Improvement Course for hospital trauma coordinators, which focuses on performance improvement. In addition, the American College of Surgeons’ Advanced Trauma Life Support (ATLS) course has become more widely available, and in Minnesota, the Comprehensive Advanced Life Support (CALS) course, which includes elements of trauma education similar to ATLS, has provided relevant trauma training to rural health care providers. Trauma system advocates in Minnesota took this into account as they developed a new proposal for a statewide system.
Developing the Minnesota Comprehensive Statewide Trauma System Plan In 2000, the federal government initiated a limited effort to help states enhance or develop statewide trauma systems. Since the terrorist strikes on Sept. 11, 2001, there has been even greater emphasis on the need for coordination of emergency response efforts. A $45,000 federal grant was awarded in October 2001 to the Minnesota Emergency Medical Services (EMS) Regulatory Board, which assembled the Trauma Core Work Group, a committee of 50-plus interested stakeholders, to begin a new effort to design a statewide trauma system. By September 2002, the work group, along with the EMS Regulatory Board, thought that the best way to further this initiative was to have the Minnesota Department of Health assume the lead agency role.
In April 2003, Dianne Mandernach, commissioner of health (and a former rural hospital administrator), appointed 14 people to a Trauma System Planning Subcommittee to continue the work. At that time, Commissioner Mandernach charged the subcommittee to “develop and publish a draft plan for a comprehensive trauma system for Minnesota.” This time, rural physicians, nurses, hospital administrators, and EMS providers were at the table. In December 2003, after eight months of meetings, the Trauma System Planning Subcommittee completed its work. (The Minnesota Comprehensive Statewide Trauma System Plan can be viewed at www.health.state.mn.us/ traumasystem.)
Four key principles guided the development of the plan:
• The system should rapidly evaluate and treat severe trauma; it should not address medical emergencies or routine injury.
• The proposed system should not disrupt existing referral patterns; rather the system should seek to continually improve the quality of care provided.
• Proper system support and education will allow many trauma patients to be treated in their own communities, with those requiring a higher level of care being assessed, stabilized, and transferred rapidly and efficiently.
• The system needs to allow for variation to accommodate the differences in geography, population, and resources within in the state; the plan should have general state guidelines but encourage enhancements at the local or regional level.
The goal is for all hospitals to voluntarily participate in the state trauma system, making it truly a statewide cooperative effort. No hospital will be required to participate at a level other than that which they select and for which they qualify for state designation or for verification by the ACS. The system is designed to match facility resources with the needs of the patient as quickly and efficiently as possible.
Blueprint of the Minnesota Trauma System
In the mid-1970s, the ACS proposed the establishment of regional trauma systems and developed criteria for the designation of trauma centers.2 Since that time, studies have confirmed that states with an organized trauma system have had decreased mortality from traumatic injuries (Table 1).3-6
The goal of a statewide trauma system is the rapid triage and transport of patients to a hospital that can provide the appropriate level of care for a given injury. Components of such a system include the presence of a lead agency with legal authority to designate trauma centers, on-site verification during the designation/identification process, written prehospital triage protocols, interfacility transfer agreements, and the presence of continuous monitoring systems supported by a trauma registry for ongoing process improvement.7 An integrated trauma system also includes injury prevention and postinjury rehabilitation.
Governance
The Commissioner of Health will be legally responsible for the state trauma system. The state trauma system will be governed by an oversight and coordinating entity called the State Trauma Advisory Council and regional entities for detailed planning, advocacy, and support. Regional oversight is not mandated but is encouraged. The State Trauma Advisory Council will consist of physicians, nurses, EMS providers, hospital administrators, and others from around the state who play key roles in statewide trauma care. The EMS Regulatory Board will provide coordination and adoption of trauma-related EMS guidelines for all licensed ambulance services and assume the lead role in the oversight of any EMS-specific trauma legislation.
Emergency Medical Services
The proposed state EMS trauma triage and transportation guideline is designed to assist EMS providers and their medical directors in identifying critical trauma patients who will most benefit from the state trauma system (Table 2). Further, the guideline also provides general direction for how these critical trauma patients should rapidly and efficiently access definitive trauma care through the local EMS system. The guideline applies to all Minnesota-licensed ambulance services. Ambulance providers that wish to deviate from the state guidelines to better meet local or regional needs may do so provided they have approval from the EMS Regulatory Board.
Designation and Verification
In Minnesota, the Commissioner of Health will designate all levels of trauma centers. There will be 4 levels of designation (Table 3). Initial designation will be for 3 years and is renewable every 3 years thereafter. All hospitals seeking designation will indicate to the Commissioner of Health the level of trauma care they believe they can—and are qualified to—provide. A site review will verify that all of the criteria are met.
Hospitals seeking to maintain or to become Minnesota Level I or II trauma centers will need to successfully complete the ACS verification standards at their own cost. Upon successful completion of this process, the Commissioner of Health will grant the state trauma center designation that corresponds to the ACS verification. Specific Level III and Level IV designation criteria are included in the state plan. Trauma teams, education, triage protocols, and a strong emphasis on performance improvement based on a trauma registry are essential features of the proposed system. Utilization of existing referral agreements will be permitted and encouraged when applicable.
Those hospitals receiving Level III designation will ratchet up the effectiveness of the state trauma system by providing quick access and rapid surgical interventions and by making the difficult-yet-timely decisions about when to transfer trauma patients to hospitals offering higher levels of care. In addition, studies have shown that with the development of a trauma system, Level III facilities see an increase in the number of trauma patients that they admit rather than transfer.8
It is anticipated that the majority of hospitals in rural Minnesota will seek and obtain a Level IV trauma center designation. Small hospitals are critical to the success of a state trauma system because they provide the first line of hospital care for traumatically injured patients. This underscores the need for the supportive environment that the trauma system aims to foster in terms of education, nonpunitive feedback on performance, and a network of transfer/referral facilities. Level IV criteria allow for a hospital emergency department to be covered by mid-level practitioners such as physician assistants and nurse practitioners if they have approved trauma education.
During the summer of 2004, the Minnesota Department of Health tested the trauma plan’s Level III and IV criteria at hospitals in Aitkin, Grand Marais, New Prague, Slayton, Tracy, Wadena, and Wyoming. The purpose of the pilots was to evaluate how realistic it was for rural hospitals to implement the trauma plan criteria. The primary emphasis was on educating staff, establishing policies and procedures for handling and reviewing trauma cases, and testing the state-developed trauma registry software. One of the key findings from the pilots was that those hospitals whose staff had received CALS training had a significant head start in meeting most of the Level III and IV trauma facility criteria in the areas of staff education, equipment, and treatment and transfer guidelines. An analysis of the cost of implementing the criteria at the pilot sites, along with a summary of the lessons learned from the pilot projects, is available at the Minnesota Department of Health Web site www.health.state.mn.us/ traumasystem.
Trauma Registry
Every hospital that participates in the state trauma system will submit trauma registry data to the Department of Health. The goal is for the trauma registry to be an accurate and complete tool that hospitals can use to judge retrospectively how policies, procedures, staffing, and outcomes data compare with aggregate data from similar hospitals. Efforts were made to balance the need for a comprehensive minimum data set that would be useful at the local level against the need for ensuring that the details of the reporting requirements are not overly burdensome. The Department of Health has developed the data registry software for Level III and IV centers and will provide ongoing support for troubleshooting and upgrades.
Costs
It is estimated that the total annual cost to administer the system will be $550,000. This assumes that between 90 and 120 of Minnesota’s 140-plus hospitals will voluntarily participate in the state trauma system. A portion of those costs will cover expenses associated with the 30 to 40 annual hospital site-verification (and reverification) visits by industry experts from outside the hospitals’ geographic regions. These experts will include State Trauma Advisory Council–approved physicians and nurses from throughout Minnesota and neighboring states. Additional costs include maintenance and analysis of the trauma registry and support for administration of the State Trauma Advisory Council and at least one working subcommittee to support hospital and EMS performance improvement.
Conclusion
At the time this article was written, proposed legislation to implement the plan was working its way through the state’s legislative and budget-development process. Although there is a great deal of statewide interest in bringing this system to fruition this year, funding may be a challenge. There will, however, be consequences for not passing trauma legislation in 2005. Our federal partners in trauma care have indicated that future federal funding will no longer support development of new systems but will instead go to established ones. Thus, any future efforts to build consensus around a plan will need to be funded by state dollars. Another consequence will be that statewide disaster planning efforts will not have the benefit of being grounded on an established trauma system designed to optimally care for individual day-to-day crises. Last, the life-saving benefits of trauma systems are not realized overnight; delays in implementing a system push those benefits further into the future.
There is widespread support for the 2004 Minnesota Comprehensive Statewide Trauma System Plan both from trauma care providers and professional associations, including the Minnesota Medical Association, the Minnesota Hospital Association, the Minnesota Ambulance Association, the Minnesota Emergency Nurses Association, the Minnesota Chapters of the American College of Surgeons and the American College of Emergency Physicians, the Minnesota Academy of Family Physicians, and the EMS Regional Programs. The consensus is that the plan is realistic, doable, and will, if implemented, reduce trauma-related morbidity and mortality in Minnesota as similar plans in other states have done. MM
David Larson is an emergency physician at Ridgeview Medical Center in Waconia and the trauma system medical director for the Minnesota Department of Health. Tim Held is the trauma system coordinator for the Minnesota Department of Health.
References
1. Mann NC, MacKenzie EJ, Anderson C. A 2002 National Assessment of State Trauma System Development, Emergency Medical Resources, and Disaster Readiness for Mass Casualty Events. U.S. Department of Health and Human Services—Health Resources and Services Administration; 2003.
2. American College of Surgeons Committee on Trauma. Optimal hospital resources for care of the seriously injured. Bull Am Coll Surg. 1976;61:15-22.
3. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA. 1994;271:1919-24.
4. Nathens AB, Jurkovich GJ, Cummings P, Rivara FP, Maier RV. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA. 2000;283:1990-4.
5. Norwood S, Fernandez L, England J. The early effects of implementing American College of Surgeons level II criteria on transfer and survival rates at a rurally based community hospital. J Trauma. 1995;39:240-5.
6. Mullins RJ, Mann NC, Hedges JR, Worrall W, Jurkovich GJ. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma. 1998;44:609-17.
7. Bass RR, Gainer PS, Carlini AR. Update on trauma system development in the United States. J Trauma. 1999;47:S15-21.
8. Richardson JD, Cross T, Lee D, et al. Impact of level III verification on trauma admissions and transfer: comparisons of two rural hospitals. J Trauma. 1997;42:498-503.