Trauma System Agenda for the Future


What is Trauma

What is Trauma Systems

The Vision

Executive Summary


Comprehensive Trauma Care System: Fundamental Components of Trauma Care

Comprehensive Trauma Care System: Key Infrastructure Elements





Appendix B - Historical Overview of Trauma System Development ummary of Recommendations

The theoretical foundations of trauma care and the essential characteristics of trauma systems have been continually refined over the past 30 years. The following discussion provides a summary of system development based on the circumstances that prompted progressive development including shifts in public interest, changes in government policy, and establishment of priorities within professional associations.

The organized care of injured patients has its roots in military models of trauma care; many of the advances in caring for major trauma patients can be attributed to the lessons learned during past military conflicts. During World War II, well-developed triage systems were instituted and wounded soldiers were evacuated through tiers of increasingly capable medical care. Throughout the Korean and Vietnam wars, the time from injury to definitive treatment was sharply reduced by transporting patients with serious injuries directly to acute care field military hospitals that delivered immediate, organized trauma care. Although the principles learned during wartime were not automatically or easily implemented at home, the military ' s success in dealing with severe injuries led to heightened public expectations about trauma care and provided an impetus for the development of trauma systems.

The first defacto trauma centers were municipal hospitals in major urban areas that mostly provided emergency services to the uninsured. Because these hospitals were usually affiliated with medical schools, injured patients received timely treatment from in-house staff officers while these staff members gained expertise in dealing with injuries. This concentration of expertise and the early development of centers of excellence for trauma care contrasted sharply with the care in suburban hospitals in the same geographic area, which did not have a similar systematic response for injured patients.

Community and public education regarding the status of EMS and trauma care peaked in 1966 with the publication of the classic National Research Council/National Academy of Sciences white paper Accidental Death and Disability: the Neglected Disease of Modern Society." 1 This landmark document reflected the gross deficiencies in prehospital care and proposed a long range plan for changes in every facet of emergency care. This farsighted report provided the basic blueprint and building blocks for subsequent improvements in EMS programs nationwide but fell somewhat short in describing the need for systems of care. Congress responded to publication of this white paper by enacting both the National Traffic and Motor Vehicle Safety Act and the Highway Safety Act of 1966, which summoned a national commitment to reducing injuries on the nation's highways. The Department of Transportation was empowered to set motor vehicle standards, fund research and programs that promoted highway safety, provide leadership for the development of regional EMS systems, and develop standards for EMS provider training. States were required to include EMS as part of their highway safety programs. Several prototype emergency medical systems were developed under the auspices of this funding that identified the essential characteristics of regional trauma systems and provided the first indications that implementation of such systems saved lives 14-16 . The unique design of an early system, the Illinois Trauma Program, which incorporated both urban and rural areas, utilized a controlled systems approach that profoundly influenced future trauma system development 17 . Based on this original legislation from 30 years ago, the National Highway Traffic Safety Administration (NHTSA) continues to develop and implement EMS programs and other traffic safety programs today.

The EMS Systems Act of 1973 was perhaps the single most important piece of legislation affecting the development of regional emergency and trauma care systems. The Act called for the creation of a lead agency under the Department of Health, Education and Welfare and identified 15 components (one being trauma systems) to assist system planners in establishing areawide or regional EMS programs. At that time, regionalizing services was viewed as one way of distributing resources more equitably while expanding access to health care systems. A substantial amount of federal funds were devoted to the establishment of an EMS infrastructure in over 300 EMS regions nationwide. A primary failure of the Act, however, was its inability to adequately stimulate initiatives to continually fund EMS at the local level.

In 1981, funding sharply declined when the Omnibus Budget Reconciliation Act altered the method of allocating federal EMS funds. EMS and trauma system funding was consolidated into the state preventive health block grant program. The purpose of the block grant concept was to shift responsibility of funding for EMS services to the states while still providing support for lead agencies that direct EMS services. States were given wide discretion regarding the use of health funds; many regional EMS management programs lost funding and were dismantled due to this change, while others responded by increasing their involvement in EMS system development. At the same time, several pivotal studies highlighted the relationship between untoward patient outcomes and lack of surgical support or delays in caring for injured patients, which drew public attention and accelerated progress towards systems development in some areas 18-21 .

In 1984, Congress authorized the Emergency Medical Services for Children (EMS-C) Program to support state-of-the-art emergency medical care for injured children and adolescents. Although the program focused on the entire continuum of pediatric emergency services, the intent was to ensure that pediatric services were fully integrated into trauma systems. In addition, the National Pediatric Trauma Registry was established in 1985 to study the causes, circumstances and consequences of injuries to children.

In 1986, the National Research Council and the Institute of Medicine conducted a 20 year follow-up analysis of advancements made since the 1966 white paper focused the nation's attention on EMS. Although the authors of "Injury in America: A Continuing Health Care Problem" concluded that considerable funding and effort had been utilized to develop systems of care, little progress actually had been made towards reducing the burden of injury 2 . A conceptual pathway for the field of injury control was introduced in this report that called for a major investment in research related to the epidemiology of injury and development of parallel prevention programs. The committee successfully advocated for the creation of a new injury research center to lead national efforts in injury control and establish research programs related to all aspects of injury including prevention, pre-hospital care, acute care, and rehabilitation. The Centers for Disease Control (CDC) was chosen as the site for this new center because of the CDC's strong relationship to state health departments and emphasis on research rather than regulation. Today, this program continues to fund trauma related research and support the growth of Injury Control Research Centers across the US.

1988, the NHTSA provided additional requisite resources for trauma system development and evaluation through establishment of the Statewide Technical Assessment Program and the Development of Trauma Systems course. The technical assessment team approach has been used by states to assess the effectiveness of individual EMS system components, as well as the interrelationship of these components in producing a comprehensive system 22 . The Development of Trauma Systems course provided states and regions with a detailed tool for system development that was tailored to their individual needs 23 .

The Trauma Care Systems Planning and Development Act of 1990, which created Title XII of the Public Health Service Act (PHSA), was enacted to improve emergency medical services and trauma care. From 1992-1994, funds were appropriated to carry out the responsibilities specified in this Act and administered by HRSA. The program was not funded in FY95. Under this program, a model trauma care system plan to use in trauma system development was written by a consensus panel of experts. 8 Many states were making significant progress 25 when Congress failed to reauthorize resources for the program in 1995. It was funded again in FY2001 and 2002. Title XII of the PHSA is responsible for improving trauma and emergency medical care through system improvement. This goal is accomplished through: (1) a grant program available to State EMS offices to improve the trauma care component of the EMS plan; (2) a grant program to improve rural EMS care; and (3) discretionary activities including research, evaluation, and grants for special EMS/trauma initiatives.

In the midst of these changes in federal policy and funding, professional health care associations have also provided guidance for trauma system development. The American College of Surgeons Committee on Trauma (ASCOT) made substantial contributions to the conceptual framework of trauma care systems by advocating for a network of trauma centers with verified capabilities. ASCOT assumed the mantle of leadership in 1976 by identifying the key characteristics for categorization of hospitals as trauma centers in the first edition of their publication, "Optimal Resources for Care of the Seriously Injured". 5 Through successive revisions, this document became recognized as the standard for trauma hospital performance. In 1987, ASCOT developed an external review program to verify hospital capabilities, which provided further incentives for the designation of trauma centers. Recently, ASCOT published a multidisciplinary work group document entitled, "Consultation for Trauma Systems," which provides guidelines for evaluating trauma system development and making system enhancements 10 . In addition, the American College of Emergency Physicians (ACEP) published "Guidelines for Trauma Care Systems," which provided a detailed description of critical prehospital care components in a trauma system 6 .

In 1999, the Institute of Medicine (IOM), with support from several private foundations, published its third assessment of the public and private response to injury. The report provided evidence of significant advances in trauma system development but also highlighted the profound gap between the current investment in system development and the magnitude of the injury problem 4 . The group recommended additional funding for surveillance, research, training and program evaluation by federal agencies.

Recent events have even further accelerated the momentum for the development of a nationwide trauma system. The Skamania Conference held in July 1998 reviewed the medical literature to quantify current understandings of trauma system effectiveness and proposed a plan for research in trauma. Participants included representatives of many different specialties in addition to trauma experts. A key recommendation from this conference was to use a national consensus process involving a spectrum of national committees and organizations interested in trauma care and prevention to design a vision document describing a trauma system for the future, including current status, a future vision, and an implementation strategy based on valid, reliable data. The Skamania Conference also recommended renewed federal funding for trauma system development.