State trauma system: Growth and growing pains

The goal of a statewide trauma system is to reduce death and disability by providing all critically injured people with timely, appropriate care. To accomplish this, the traditional care model, which focused exclusively on large, urban trauma centers, has been replaced by an inclusive approach in which tertiary centers, small hospitals and Emergency Medical Services (EMS) interact seamlessly in a single, coordinated network.

Ideally, such a system accommodates regional variations, evolves with changing resources, provides services across the continuum of care, and is the foundation for disaster preparedness and response.

Texas, which has one of the most mature statewide trauma systems, is an example of how care can improve even when all the pieces don't come together perfectly. Since the implementation of its trauma system, Texas has seen a reduction in motor vehicle fatalities, a 15 to 20 percent increase in survival of severely injured patients and improved disaster preparedness.

But not all states have Texas-size experience or funding, says Chris Ballard, R.N., EMT-P, trauma system coordinator for the Minnesota Department of Health. Most, like Minnesota, are relative newcomers with nominal budgets and small staffs.

Minnesota Statewide Trauma System

Still, the Minnesota trauma system, now in its eighth year, has grown from six designated hospitals in 2005 to 123 today. Nine are Level I or Level II trauma centers and more than half are Level IV hospitals.

"We're bringing knowledge and information from the big centers to the small hospitals," Ballard says. "The large centers take the lead and help everyone else ramp up. They have an intellectual database on how to care for patients. We don't all have that experience, so we need some help from people who do. We're linking folks and establishing a network so the collective knowledge is shared with everyone in the region and across the state. The result is that patients benefit and the knowledge and expertise are shared."

One of the chief means for transferring knowledge is through performance improvement (PI), which helps hospitals better manage trauma patients on a daily basis and, as an added benefit, also makes them more prepared to deal with mass casualty incidents (MCIs).

Ballard explains, "The most common MCI in rural areas is a car crash, which isn't unusual, but in a small town with limited resources, it can really tax hospital resources. Having a methodical approach to triaging and managing patients, identifying injuries and making disposition decisions makes handling MCIs easier because patients don't linger while the staff try to figure it out. And in fact, things are going smoother now because we responders have established roles and hospitals have previously discerned their resource capabilities and developed a plan for the patients' disposition. It's still chaotic and challenging, but patients move through it more smoothly."

SMRTAC and PI

He adds that the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC), one of six such committees in the state, has begun to implement a regional PI process.

"They've been able to identify what the big issues are because SMRTAC has been doing a lot of work developing practice management guidelines throughout the entire region. That seems like a monumental task — and it is — but somehow they've pulled it off, mainly because there is such competent, selfless, talented leadership in that region."

Regional performance improvement is critical to maintaining an integrated trauma system because it addresses larger scale issues, such as global transfer times and global EMS resources.

Ballard says the next step is undertaking PI at the state level and looking at systemwide indicators and opportunities for improvement.

"We're particularly looking at improved data collection," he says. "Epidemiological analysis can drive public policy, but right now the data set is lacking, and it really needs to be complete and dependable to move the system forward."

The problem is that some hospitals don't submit complete data to the online registry, and others don't submit any data at all. Often, it's a matter of scarce resources.

Ballard points out that "a trauma program isn't a moneymaker, so whatever resources are allocated to it have to come from somewhere else. We just have to take a leap of faith that an investment on the front end will pay dividends in the future here in Minnesota as it has in other states.