Regionalized health care and the trauma system model

Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.

Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).

The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."

One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.

Regionalization: The trauma system model

In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).

What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).

Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).

The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.

These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).

The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.

The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.

National Trauma and Acute Care Surgery Center Network: A Proposal

I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.

Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).

Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.

A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.

The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.

How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).

In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).

So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).

Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.

Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.

Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.

Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.

Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).

The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."

One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.

Regionalization: The trauma system model

In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).

What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).

Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).

The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.

These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).

The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.

The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.

National Trauma and Acute Care Surgery Center Network: A Proposal

I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.

Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).

Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.

A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.

The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.

How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).

In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).

So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).

Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.

Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.

Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.

Editor’s Note: This editorial is based on the Presidential Address given by Dr. Jurkovich at the 2012 annual meeting of the Western Surgical Association.

Regionalization of health care is part of the larger dynamic of change in medicine that includes an aging population, financing reform, and generational identity issues of physicians in training and future providers of care. Trauma systems provide a model for effective regionalized care, and in this context, I propose a network of national acute care surgery hospitals built on this model. But there are lessons that can be learned from 35 years of trauma systems development and implementation that can be applied to a network of national acute care surgery hospitals (J. Am. Coll. Surg. 2012;215:1-11).

The problem of lack of emergency surgical resources has been noted since the beginning of the 21st century, and has received considerable attention from a wide variety of public and private organizations and government agencies. A cover story of U.S. News and World Report in 2001 was entitled "Crisis in the ER." The influential Institute of Medicine (IOM) three-volume report in 2009 entitled "Future of Emergency Care" noted that hospital-based emergency care was as the breaking point, with overcrowding of emergency departments (ED), boarding of patients in the ED, with ambulance diversion and uncompensated care being the most pressing problems. The Robert Wood Johnson foundation report authored by Dr. Mitesh B. Rao and his colleagues in 2011 highlighted the shortage of surgeons who take emergency call and suggested that "three-quarters of the nations’ emergency departments do not have enough on-call coverage by surgical specialists to meet the demand for round-the-clock specialty care."

One of the key solutions suggested in the IOM report was to develop regionalized on-call specialty care services. The concept is that if hospitals cannot find willing (or able) surgical coverage for certain surgical urgencies or emergencies, then the patients should be sent to regionalized centers of care that can provide these services. The burden on the patient is significant: The patient may have to travel some distance to receive health care. The burden on the receiving hospital is also significant: The patients often are the most challenging and underfunded in medicine. The burden on the profession of surgery is also significant, if often overlooked: a further erosion of the perception of our profession from one concerned primarily with the sick and suffering and to a perception that specialty surgeons are more concerned about lifestyle and personal gain. Nonetheless, this does appear to be the best model for the future of surgical care. The purpose of regionalization of care is to consolidate complex and high-technology medicine into regional centers with adequate surgeons in all specialties, in the hope that this will ensure quality and cost-effective care. It is an opportunity for surgical leadership to become involved in this dramatic change in medicine.

Regionalization: The trauma system model

In 1976, the American College of Surgeons Committee on Trauma published the first version of "The optimal resources for a hospital." The eighth version will be released shortly. This document is the authoritative source on trauma center function. Initially developed to serve as a guideline for what resources were required for a hospital trauma center, a name change in 1990 to "Resources for Optimal Care of the Injured Patients" expanded the implications and reach of these guidelines (J. Trauma 1998;47(3 Suppl.):S1).

What makes trauma center care better? In a study of 31 academic Level 1 trauma centers, the higher volume trauma centers (more than 650 major trauma admissions per year) had improved outcomes, particularly for the sickest patients (JAMA 2001;285:1164-71).

Improved critical care also seems partially responsible for better outcomes at trauma centers. The ability of trauma centers to salvage patients with complications or severe shock and injury appears to be a defining characteristic of those centers with the better outcomes. In addition, trauma intensive care units that are "closed" and staffed by surgical critical care surgeons achieve the best results (J. Trauma 2011;70:575-82; Arch. Surg. 2003;138:47-51;discussion 51; J. Trauma 2006;60:773-83;discussion 783-4; Ann. Surg. 2006;244:545-54).

The reasons trauma centers have improved outcomes appears to be multifactorial, injury-pattern dependent, and not entirely understood. It appears it is not just the hospital designation that makes the difference, but the design and effectiveness of system integration that is equally important.

These examples emphasize the point that a series of activities and actions is required for regionalizing care, not simply forcing a specific population of patients into one hospital. The model trauma system plan written by the HRSA in 1992, with help from the ACS Committee on Trauma and CDC continues to serve as the benchmark for trauma system design (Health Resources and Services Administration. A 2002 national assessment of state trauma system development, emergency medical services resources, and disaster readiness for mass casualty events. Washington: U.S. Department of Health and Human Services, 2003). This plan is based on work and definitions first described by West et al., and modified by Bazzoli et al. (JAMA 1995;273:395-401; JAMA 1988;259:3597-600).

The essential components of a trauma system are designating hospitals as having a specific range of resources, proscribing prehospital triage protocols that allow the selective bypassing of nontrauma centers or lower levels of care, requiring inter-facility transfer agreements, developing quality assurance programs with teeth and the ability to impact change, ensuring regional or state-wide coverage, and importantly, limiting the number of centers based on need for patient care. These steps are rarely accomplished voluntarily, but require government regulations that also provide financial incentives to cover the large number of uninsured trauma patients.

The effectiveness of this approach to regionalized care is remarkable. A recent paper looked at 2.7 million trauma patients from the National Inpatient Sampling (NIS) data between 1995 and 2003 (JAMA 1988;259:3597-600). This paper defined major trauma as patients with a mortality risk of 10% or greater based on injury severity as calculated using ICD-9–based Injury Severity Score (ICISS). They defined high-volume trauma centers as those that treat 915 or more major trauma patients a year. In the United States, only 7% of hospitals meet this threshold, yet they provide 60% of the total major trauma volume care in this country (Figure 7). That’s effective regionalization. That’s an effective concentration of resources that saves lives.

National Trauma and Acute Care Surgery Center Network: A Proposal

I would like to propose the creation of a national network of high-volume, high-acuity trauma and acute care surgery medical centers. Let’s call this the National Trauma and Acute Care Surgery Centers Network (NTACS Network). There are currently about 200 Level 1 trauma centers in the United States, with 107 verified by the American College of Surgeons (ACS) and the rest verified by state agencies using similar (but not exactly the same) criteria. The ideal population volume per Level 1 trauma center is under discussion, but probably a minimum of 1-3 million people per Level 1 trauma center is most appropriate. Any fewer and the volume of cases is diluted and efficiency of concentration and expertise is lost. As the population of the United States is about 300 million people, the ideal number of trauma centers would be between 100 and 300. I tend to favor fewer Level 1 centers, and a greater concentration of the most difficult cases and expertise. So, for the purposes of this proposal, let’s say one NTACS Center for every 2.5 million people, meaning a network of 120 such centers across the country would be required. This density of trauma centers is readily met (and often exceeded) in urban and suburban environments, but is more difficult to achieve in the rural Western states.

Staffing and resources for this NTACS Network would be consistent with what the ACS requires for verification of Level 1 trauma centers. From the standpoint of surgical coverage, a cadre of general surgeons with specific training and expertise in trauma, surgical critical care, and emergency general surgery – the acute care surgeon model – would be ideal coverage for this type of center (J. Trauma 2005;58:614-6; Surgery 2007;141:293-6).

Eight to ten such surgeons, with resident and/or mid-level providers, would provide coverage for surgical critical care, emergency general surgery, trauma surgery, research and education, and administrative duties, implying a need for 960-1,200 such surgeons. These surgeons would provide primary surgical care for trauma, critical care, and emergency and elective general surgery, with 1 night a week in house on call, and time for research and administration, and adequate vacation and sick-leave coverage.

A strategy for interesting the new generation of surgeons in this national network of trauma and acute care surgical centers could focus on incentives to draw the best and brightest. Loan forgiveness programs for medical school education could be applied to surgeons working in such centers. Volunteers could be recruited, perhaps establishing an AmeriCorps for physicians. With adequate manpower, fixed time off, set schedules, and protected time after night coverage and for academic activities would be easier to arrange. Fixed minimum incomes with volume and work performance incentives could be applied. Malpractice limits, similar to the protection state and federal agencies enjoy, could be applied. Facilities participating in the network could readily become academic centers of excellence. The academic productivity and clinical research material from a well-organized network of such facilities would be phenomenal, and serve as the model for multicenter trials and studies of a wide array of interventions, procedures, and practices. Standardization of care would be much easier to obtain, as would dissemination of new information and practices.

The cost for this national network of trauma and acute care surgery centers can be estimated, if only on the back of a napkin at this point. If each hospital had about 300-400 beds, and an estimated annual operating budget of $600 million, the total operating costs for 120 such centers would be $72 billion. If one-half of that money came from third-party health care insurance sources, the federal costs would be about $36 billion, certainly less than the $50 billion proposed in the 2012 Veterans Affairs budget for direct medical care (Office of Management and Budget, Fiscal Year 2012 Budget of the U.S. Government. Washington: USGPO, 2012. p. 137-49). These figures can be compared with the wide range of public dollars spent by communities to provide safety-net coverage. For example, the city and county of Denver budgets about $27 million annually to Denver Health, while the city of San Francisco supports San Francisco General with about $38 million annually from their general fund.

How close are we to having the manpower to meet the needs of such a network of hospitals? Over the past 4 years, 10%-12% of the current 1,100 graduates of general surgery training programs go on to do a surgical critical care residency. That’s actually more than or equal to vascular, pediatrics, hand, or thoracic surgery specialty training. In 2009 there were 2,583 surgeons who take their board in surgical critical care, and 1,204 of them have been recertified at least once (J. Trauma 2010;69:1619-3).

In addition, there is the ongoing development of acute care surgery training programs, spearheaded by the American Association for the Surgery of Trauma, with a goal of 20-30 such training programs. (J. Trauma 2005;58:614-6; J. Trauma 2007;62:553-6; J. Trauma Acute Care Surg. 2012;72:4-10; J. Trauma 2010;68:753-60).

So we have the manpower, and we have a great distribution of trauma centers across this country, with authoritative legislation in most of the states. A total of 83% of the population is within 1 hour of trauma center care by ambulance or helicopter (JAMA 2005;293:2626-33).

Western rural states have the unsolved problem of adequate access to trauma center care, primarily because the population density cannot support such highly specialized centers. But with improved organization of regionalized transportation, this issue could be addressed, and these patients and resources concentrated. Urban America has a different problem in some locations, which is the oversubscribing of trauma centers because of ego, greed, lack of cooperation, and a presumed drive for prestige. This problem could be solved with legislation and changes in funding for trauma and acute care.

Trauma care systems are a model for regionalization of all time-sensitive illnesses, not just trauma, and not just surgical issues; the integrated trauma system model can be the future of regionalization of all health care.

Dr. Jurkovich, an ACS Fellow, is chief of surgery at Denver Health, and vice chairman of surgery, University of Colorado in Denver.