Patient care improves when trauma providers align

Communication and cooperation are the key to improving patient care in trauma regions, according to Ronald M. Stewart, M.D., chair of the department of surgery at the University of Texas Health Science Center at San Antonio. Dr. Stewart is also chair of the Southwest Texas Regional Advisory Council for Trauma, which oversees a 26,000-square-mile region serving 2.5 million people.

"What it really boils down to is a strong, collaborative working relationship between EMS and the hospitals, nurses and physicians in the region," he says. And that is difficult to achieve without an active effort from those participating in the system. People have to be willing to meet, talk and develop an infrastructure. When structured communication and cooperation exist within a trauma system, patient care improves and mortality decreases."

Texas is a convincing example. Mortality rates in the state were once significantly higher than the national average. But after the implementation of the state trauma system, the gap narrowed by 35 percent and mortality rates are now in line with those of the country as a whole.

"That reduction in mortality comes to 6,728 lives — the size of a small Texas town," Dr. Stewart says. "We have a lot of complicated problems, but when you bring together people across the entire spectrum of a region who know what the problems are — if you get them working together, talking and cooperating — they come up with solutions that make sense."

He points to a recent example involving fall-related injury and mortality. "If you ask me what the leading cause of death in our region is, I would intuitively say motor vehicle crashes because that's what we see at our Level I trauma center. But it turns out that falls are also a big problem. As a Level I center, we weren't aware of that because folks injured in falls tend to get treated in their own communities. Once we put all of our data together with that of the Level III and Level IV hospitals, we realized we had to do something about falls. So now we work on fall prevention and care of patients injured in falls."

That same process — bringing all the care providers in a region together to discuss problems and find solutions for them — worked almost from the beginning. Twenty years ago, just after Texas instituted its regional trauma system, it became obvious that the interhospital transfer system wasn't working. Severely injured patients were often stranded in small hospitals because the system didn't facilitate their transfer to higher levels of care.

Dr. Stewart says this was another problem that simply "wasn't on the radar" of the big trauma centers, but "once we got everyone in the region together, it became crystal clear that we had a major access problem, and it was one of the first things we handled."

The solution was to establish a one-call-does-it-all system in which a referring hospital can transfer patients to one of three Level I trauma centers — and obtain administrative preapproval for those transfers — with a single call.

"Our service area covers 26,000 square miles. Some people are hundreds of miles away from a major hospital, so establishing access is extremely important," Dr. Stewart points out. "But improving local care is just as important. Of late, we've made a concerted effort to develop and improve pre-hospital care in remote regions. With a regional trauma system, some of these problems become more evident than they would if you were only dealing with the patients in front of you."

Consensus is crucial

Dr. Stewart says that although his region is geographically, economically and politically diverse, there is very little disagreement on major issues. "We've never had a nonunanimous vote," he explains. "All of our decisions are based on consensus. That's absolutely crucial. And sometimes we have to talk a lot and discuss issues at length, but ultimately, we can all live with and support the decisions that are made because our fundamental focus is on what's best for the care of the patients in the region, not what's best for a particular trauma center or group."

He adds, "We were our own worst enemies when we started 20 years ago, by which I mean we would polarize along different stakeholder lines. It was hospitals versus EMS, physicians versus hospitals, urban versus rural, Dallas versus Houston. One of great advantages of this process is that when you get people together in a room, when they attend monthly meetings and they get to know one another, it's much harder to polarize along those lines. It really changes the dynamic."

Breaking down barriers not only benefits patients but also is good business. Dr. Stewart says it's very easy for state legislators to do nothing when various stakeholders are fighting with each other and competing for money. But when physicians, EMS, nurses and hospitals are all aligned around care of the patient, it's much harder to deny funding. Even in these partisan times, that hasn't changed.