Needs-based Assessment of Trauma Systems: A Survey of the Membership of the Western Trauma Association

Special Article – Trauma System

Austin J Surg. 2019; 6(1): 1158.

Needs-based Assessment of Trauma Systems: A Survey of the Membership of the Western Trauma Association

Smith RS¹*, Ciesla DJ², Namias N³, Brakenridge SC¹, Mercier NR4 and Moore FA¹

¹Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, USA

²Department of Surgery, University of South Florida, USA

³Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital and the University of Miami, USA

4University of Arkansas for Medical Sciences, USA

*Corresponding author: Smith RS, Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA

Received: November 12, 2018; Accepted: January 07, 2019; Published: January 14, 2019

Abstract

Background: Widespread proliferation of Trauma Centers (TC) in many regions of the United States currently threatens several state trauma systems. Following a 2015 consensus conference, the American College of Surgeons Committee on Trauma published a Needs-Based Assessment of Trauma Systems (NBATS) tool to assist trauma systems in determining the number of trauma centers needed within a region. Acceptance of NBATS has not been widespread and some have opined that NBATS criteria were not appropriate.

Methods: A 16-question Lickert scale survey instrument, based on major components of NBATS, was made available electronically to the membership of the Western Trauma Association (WTA). If an item received 75% support (agree, strongly agree), an item was considered a consensus opinion. If 51% agreed or strongly agreed, the component was judged majority support.

Results: 167 members (71%) responded.9 questions received consensus support: (1) an assessment tool is needed (2) TC designation should be based on need (3) needs of patients should be held above the interests of stakeholders (4) justification for a new TC should be mandatory before designation (5-6) too many or too few TCs will adversely affect trauma care (7) distance between TCs should be considered (8) the role of academic level 1 TCs should be preserved (9) the minimum TSA population to support a Level 2 TC is 600,000. Two questions received majority support: (1) designation of a new TC should be deferred if a functioning TC is present in a TSA of 1.5 million (2) a new TC should decrease transport times by 15 minutes.

Conclusion: There is broad support for a trauma system assessment tool, but the composition of the tool remains controversial. The expert opinion of the WTA membership should be considered in the future development of trauma system assessment tools.

Keywords: Trauma center; Trauma system; Trauma designation; Needs based assessment for trauma systems

Introduction

In many regions of the United States, proliferation of Trauma Centers (TC) has occurred [1-11]. For example, the Florida trauma system expanded from 22 trauma centers in 2010 to 32 in 2016 while population of the state increased by 9.6% during the same period. Historically, trauma centers have most frequently been associated with busy public hospitals in urban settings. The injured patients cared for in these urban centers have whimsically been referred to as “the knife and gun club”, although vehicular related injuries usually represented the leading mechanism of injury. Of note, these centers concentrated a large number of severely injured patients that was important to meeting their commitment to education, resident training and research. University affiliation was, and is, the norm. Trauma care has not been considered as a profitable service line in many trauma centers, but instead, trauma services were viewed as a valuable resource to the community and region akin to police, fire and pre-hospital medical services. Changing national demographics overt the past 2 decades have dramatically changed the patient populations at the majority of trauma centers. Penetrating injuries from gunshot and stab wounds, while still a major public health problem have actually decreased in number since the 1990s. Road traffic safety initiatives, such as increased utilization of seat belts, air bags and intense efforts to reduce drunk driving, have stabilized the incidence of motor vehicle crash injuries. Falls in the geriatric population have increased dramatically and in many trauma centers represent the most frequently encountered mechanism of injury that results in admission [3-6]. The change in the types and number of patients admitted to trauma centers has also changed the financial fundamentals of trauma care. Geriatric patients and occupants of motor vehicles are much more likely to have insurance coverage. This dramatic change in payer mix has made trauma care profitable or at least budget neutral, in many trauma centers [4-6].

Due to many factors, a proliferation of trauma centers has been noted in many regions. The majority of “new” trauma centers have been Level 2 or 3 trauma centers established at existing community hospitals. Many of these facilities are in metropolitan areas already served by one or more Level 1 trauma centers. The increase in the number of trauma centers has been disruptive to some trauma systems and threatens the ongoing organization and oversight functions of several state trauma systems. There has been dilution of the volume of seriously injured patients that has threatened their education and research missions.

The American College of Surgeons Committee on Trauma (ACSCOT) has recognized the real and potential problems associated with the proliferation of trauma centers, which include increased health care costs, destabilization of existing trauma systems and degradation of the research and educational missions of long standing trauma centers. Conversely, the COT has recognized that too few trauma centers in a region is also quite problematic. To begin to address these issues, the ACSCOT sponsored a consensus conference in 2015 with the goal of developing methods of assessment that could be used by trauma systems to determine the appropriate number of trauma centers in a region. Following the consensus conference, the ACSCOT published a Needs-Based Assessment of Trauma Systems (NBATS) tool to assist trauma systems in determining the appropriate number of trauma centers needed within a region. The NBATS tool developed by the ACSCOT was quite similar to an assessment tool previously used by the Florida Department of Health [7]. Acceptance of NBATS has not been widespread and some have opined that specific NBATS criteria were not appropriate. As a result, the ACSCOT has scaled back implementation of NBATS until additional opinions and data are considered. To assist the ACSCOT in developing a subsequent, and hopefully, more widely accepted version of NBATS, a survey instrument based on the original version of the NBATS assessment tool was developed. Since it is well recognized that the membership of the multidisciplinary Western Trauma Association (WTA) are experts in trauma care and trauma systems, the opinions of this Association represent a significant body of expert opinion.

Methods

A 16 question Lickert scale survey instrument, based on the major components of NBATS, was developed by the authors with input from a number of additional trauma medical directors, trauma surgeons and emergency medicine physicians and other healthcare providers actively involved in trauma care. An initial test of the survey instrument was conducted by offering the survey to the trauma medical directors in Florida. Additional survey items were added to provide additional clarity of opinion based on the feedback provided by this group. The survey was made available electronically to the membership of the WTA by emailing an internet link to the survey. Additionally, the survey link was announced at the 2017 Western Trauma Association meeting. If an item received 75% support (agree, strongly agree), an item was considered a consensus opinion. If 51% agreed or strongly agreed, the component was judged to have majority support. If a survey item did not receive support from greater than 50% of the respondents, this item was determined to lack consensus. Anonymity of the respondents was maintained by the electronic survey platform. The authors did not have access to the identities of the survey respondents. Respondents were prevented from taking the survey more than once by the electronic survey instrument. This survey was performed to summarize the opinions of experts in trauma care, and as such, dealt with subjective responses. Therefore, a statistical analysis was felt to be unnecessary and inappropriate.

Results

167 members (71%) responded to the survey. Nine questions received consensus support: (1) an assessment tool is needed to assist trauma systems in determining the appropriate number of trauma centers, (2) trauma center designation should be based on the needs of patients within a region or trauma system, (3) the needs of the patient population should be held above the interests of stakeholder groups such as a hospital or hospital system, (4) justification for the need of a new trauma center should be mandatory before designation of a new trauma center occurs (5) too many trauma centers within a trauma system will adversely affect trauma care, (6) too few trauma centers will adversely affect trauma care, (7) the distance between existing trauma centers and proposed additional trauma centers should be considered, (8) the role of academic level 1 trauma centers should be preserved (9) the minimum TSA population to support a Level 2 trauma Center is 600,000 (Table 1). Two survey items received majority support: (1) designation of a new trauma center should be deferred if a functioning trauma center is present in a TSA of 1.5 million, (2) a new trauma center should decrease medianpatient transport times by 15 minutes (Table 2). Majority support was not reached for the following survey items: (1) using a quantitative formula to determine the number of trauma centers for a trauma system (2) community support as a valid indication for a new trauma center, (3) median transport times greater than 30 minutes is a valid indication for a new trauma center, (4) the minimum TSA population for a Level 1 trauma center, and (5) the number of patients with an Injury Severity Score (ISS) greater than 15 patients needed to support a Level 1 TC (Table 3).