The big picture of Arkansas's emerging trauma system, a statewide web of ERs and ambulances and doctors and nurses fashioned to save lives and improve outcomes for the injured, can be told in numbers.
Trauma deaths last year, 2,119; number of Arkansas trauma centers now, zero. Levels of care within the system, 1 (highest) through 4 (lowest). Hospitals wishing to take part in the state's new system, 69 ? five of them seeking the top Level 1 designation, including three from out of state. Money to set up the system this year, $13.5 million. Money to sustain the system in 2011, $20.3 million.
Total state investment in the trauma system, $53 million ($25 million in 2010, $28 million in 2011). Where the money will come from, a new 56-cent tax on cigarettes legislated earlier this year.
A number that matters to Terry Collins, however, is one ? the boy that the trauma program manager at the University of Arkansas for Medical Sciences believes might be alive today had he gotten the right care at the right hospital quickly enough to stop the bleeding from his ruptured spleen.
In an interview earlier this year, before the legislature approved the tobacco tax and trauma system bills, Collins sounded anxious. “We've been fighting for this for 15 years,” she said. Who knows how many lives were lost needlessly, she wondered, while legislative attempts at creating a system went unfunded. Her words were echoed by Health Department director Dr. Paul Halverson at a recent meeting of primary care doctors. “A lot of people died who didn't have to,” he said.
Based on data from other states that have trauma systems (Arkansas is said to be one of only three in the U.S. without one), a system could save anywhere from 200 to 600 lives a year, Dr. James Graham, chief of emergency medicine at Arkansas Children's Hospital, said.
Along with dollars for hospitals, the tobacco tax is expected to provide, over the next two years, $4.8 million for emergency medical services; $7.4 million for a central call center to direct patients to the appropriate hospital and to create a trauma registry, $1.5 million for rehabilitation programs and $425,000 for a performance review board.
The goal: Getting trauma victims to the right hospital within the “golden hour” after injury, assisted by a new law that allows ambulances to go to the most appropriate, rather than the closest, hospital; better access to the state's “dashboard” computer link between hospitals, and the paramedic call center to direct trauma traffic. Better-trained emergency personnel; beefed up ER staffs. A trauma registry that will show how and where people are being hurt and what their outcomes are. Coordinated rehabilitation services. A public better informed on how to prevent injuries in the first place.
“A lot of people think this is how [trauma care] is done now,” the Health Department's Halverson said. It is not, and when people learn that “they're disturbed.” But the state will be closer to that notion in two years, he says, when the trauma system will be up and running.
Some have questioned Graham's figures on lives saved, based on improvements seen in other states. Some are so cynical as to wonder if $53 million to save as few as 200 lives is worth it.
But better outcomes will be measured not just in terms of lives saved. For every death, Children's Graham says, there are three severe disabilities; if you've been treated for serious injuries at a trauma center, you've got a 1 in 5 times better chance of “walking out of a hospital independently and not having to use a wheelchair,” he says, than from a hospital that is not a trauma center. Reduced serious injury means fewer people will be out of a job, fewer will need state assistance.
Then there are those who wonder if $53 million will be enough to make any difference in Arkansas's terrible trauma statistics.
Arkansas trauma deaths are 31 percent higher than the national average. There are more car crashes, suicides, homicides and fire deaths on average in this state than the national average. Deaths from fire are higher in Arkansas than any other state.
The state's investment won't come close to compensating hospitals for the cost of taking care of the seriously injured; ERs, where the highest number of uninsured or underinsured patients are seen, are money pits. UAMS, for example, loses $5 million to $6 million a year on its emergency department. Level 1 and some level 2 hospitals will use their trauma grants (funded by general revenues paid into a revolving fund at the Department of Health) to recruit surgical specialists and offset other costs, such as on-call pay at private hospitals.
Signing on as a trauma center will require a “new level of commitment” by the hospitals, Halverson said. After paramedics assess a patient and decide where he'd be best treated, they'll alert the appropriate hospital ? and the hospital can't say no. In devising the system, Halverson said, “We did not say ‘will you take' [the patient]?” Instead, the call center is telling the hospital, “You have a patient inbound.”
Meeting the rules and regulations for the levels of care may also require hospitals to spend more than they receive from the state.
The state Trauma Advisory Council has worked for 16 years to establish a trauma system. Authorized by state legislation, the Board of Health published the first set of rules and regulations drawn up by the council in 1993. The system got no takers. The concern then, as now, was how to pay for the stepped-up trauma care ? including specialty surgeons available around the clock at Level 1 and 2 centers.
As the trauma system idea began to percolate, University of Arkansas for Medical Sciences' ER earned verification as a Level 1 from the American College of Surgeons. (The state has based its current requirements on the ACS standard, with some modifications.) White River Medical Center was verified as a Level 3, which doesn't require a trauma team but does require an on-call general surgeon for designation from the ACS.
But attempts to get state funding for the system fell short, and the hospitals, seeing no help down the road, let their verifications go.
“We made a bunch of dumb mistakes” in attempts to get the system funded, UAMS trauma surgeon Dr. John Cone said. Cone, one of the founders of the Trauma Advisory Council, said doctors have gotten an education in politics over the years. The legislature came close to approving a system in 2007, passing bills in both the Senate and House, but compromise over differences in the bills couldn't be worked out. This year, in what might be seen as the most health-conscious General Assembly ever and with a big push from Gov. Mike Beebe, a more specific trauma system law was hammered out and a tax to pay for it was passed. (Other new laws to reduce injuries: New restrictions on teen-aged drivers and a primary seatbelt law. Untouched: The law that allows motorcycle riders to go helmetless, at greater risk to expensive head injuries.)
Ironically, one of the pillars of the trauma system, a $5 million one-time grant to emergency medical services for system start-up grants, ended up in the state general fund's category B1. That category is being funded only at 18 percent.
The $5 million was to be spent to hire additional emergency personnel, do training and add communications equipment. Denise Carson, president of the Arkansas Ambulance Association, said ambulance services are “going to do whatever we can to make the trauma system work.” But, she added, “It will be very difficult because we are already short of personnel as it is.”
The state Health Department is looking at ways to make up for the loss of funding, including providing training in prehospital trauma care out of its budget and applying for grants. “We're looking under all the rocks,” Halverson said.
The Health Department and representatives from ambulance companies have worked out a plan to disburse the $2.3 million the emergency services will get in 2010 as block grants.
On Aug. 14, the Trauma Council approved the applications from the 68 hospitals that applied. The legislature will review the grants this fall; Donnie Smith, director of the Center for Health Protection at the Health Department, said the grants should be available at the first of November.
In-state Level 1 hospitals (UAMS and Children's) will get $1 million and out-of-state Level 1s (The Med and Le Bonheur in Memphis, which care for Arkansans from East Arkansas, and St. John's at Springfield, Mo., which takes patients from North Arkansas) will get $500,000. The Med's inclusion in the system has been a given from the start, considering that it serves all of East Arkansas, much of the care uncompensated. In 2007, The Med treated 2,000 Arkansans at a loss of more than $10 million. The other three hospitals were invited in late spring to apply.
Level 2 centers (Baptist Health in Little Rock, St. Joseph's Mercy Medical in Hot Springs, Jefferson Regional Medical Center in Pine Bluff, Sparks Regional Medical Center in Fort Smith and St. Vincent Infirmary Medical Center) will also get $500,000. Level 3 hospitals will get $125,000 and Level 4 hospitals $25,000. The hospitals will get half in November and the remainder after an on-site review confirms they are meeting the standards of their level.
UAMS and ACH doctors maintain they were already operating as Level 1 hospitals: They have general trauma surgeons, trauma teams and specialists ? neurosurgeons or someone designated by the chief of neurology, orthopedic surgeons, hand surgeons, ophthalmic surgeons, etc. ? available around the clock. They also operate research programs in emergency medicine and offer surgical residencies.
There will never be enough state dollars to fill the emergency department's deficit, said R.T. Fendley, senior associate director for finance at UAMS. But, he said, the dollars may help that hole from getting bigger. “We're ecstatic to get $1 million,” Fendley said.
The Trauma Advisory Council decided not to “micromanage” the way hospitals spend their grants, Halverson said. Hospitals have varying needs. It was thought, Fendley said, that most would spend 30 percent on doctors and 70 percent on training and equipment. UAMS reverses that percentage; it will spend 60 percent ? $600,000 ? to help offset the cost of adding general trauma surgeons to the staff and requiring surgeons to spend time out of the OR in deciphering trauma registry data. The remaining 40 percent will go to equipment and administrative staff.
UAMS now has two and a half trauma surgeon positions on its team; Cone wants to see five. That growth will come “incrementally,” he said.
American College of Surgeons rules for the Level 1 trauma designation require hospitals to have neurosurgeons on call and close by. But neurosurgeons, especially those who work on head injuries, are scarce in Arkansas. The state modified the ACS standard to require only that Level 1 hospitals have, in-house, doctors, not necessarily neurosurgeons, who can stabilize and diagnose neural trauma. Neurosurgeons must be available on call. UAMS has six neurosurgeons available, Cone said.
The trauma system “is a godsend,” chair of UAMS' emergency and trauma department Dr. Marvin Leibovich said.
Leibovich, who with Cone was co-chair of the first Trauma Advisory Council, said with additional staffing ? including intensive care unit specialists ? UAMS should always be ready to take care of patients. His vision, he says, is that UAMS will no longer go “on diversion” ? alert the ambulance services that it is full and can't accept patients until further notice. Children's Graham recalled a case in which a man collapsed at an event the doctor was attending on a day when everyhospital in the city was on diversion. The problem of diversion ? which is a problem of capacity ? is a problem that won't be solved by state dollars, Graham said. But the coordinated system of patient delivery should smooth out some problems. The creation of Level 2 hospitals ? which health professionals say is crucial in the new trauma system ? should relieve some of the burden now on Level 1s.
Leibovich is optimistic. In future, tales of patients who died because they couldn't get help as quickly as they needed “will be stories from the Dark Ages,” the UAMS surgeon said.
Graham said ACH would some of its trauma dollars in recruitment ? the hospital is currently seeking a urologist and nurse anesthetists. But the important change, he said, will be that “we will be operating within an organized system,” one that should make trauma care more efficient.
Five percent of the children who come to Children's Hospital because of trauma have been to two hospitals previously. Some should have come to Children's first. As an example of how important expeditious diagnosis and delivery are, Graham gave this example of a case at Children's: A teen-ager driving an all-terrain vehicle at a high speed drove into a barbed wire fence and was garroted. The local EMS recognized the severity of the injury and called a helicopter, which was able to pick the teen-ager up at the scene of the accident. The teen-ager was conscious at that point, but as the helicopter was nearing Children's, the paramedic onboard called to say the boy was losing his airway. A trauma surgeon waiting on the helicopter landing pad dashed to the 'copter after it landed and treated the teen-ager while he was still on board, putting a plastic tube into his windpipe. “He turned pink again,” Graham said, and was rushed to the operating room.
The case is one that “worked out well but demonstrates how it could have been horrible.” The EMS did the right thing, the air service was available and the paramedic on board alerted Children's to his change in condition, the trauma surgeon was there to treat him instantly. Everything had to be right for the good outcome that resulted.
Sometimes, it's not, as in the tragedy nurse Terry Collins referred to. In that case, a 16-year-old was in a crash and trapped in the car. The 911 operator dispatched an EMS service that didn't have the proper equipment to extricate him. The fire department had to be called. After the boy was removed from the car he was taken to a small rural hospital, which didn't offer the surgical specialties the injuries called for. Several hours after the crash, the teen-ager made it to UAMS, “but there was nothing we could do,” said. He bled to death. “If we had seen him from the scene he most likely would have survived.”
Hospitals may be able to ask for more money as they apply for sustaining grants in 2011, when the pot will grow by $6.5 million. The Trauma Advisory Council hasn't yet nailed down what factors will go into making second-year awards, but the volume of patients a hospital sees, its uncompensated expenses and performance should be part of the equation.
The trauma designation will bring in added compensation from Medicare, which pays extra when a trauma team is activated. UAMS is currently talking to commercial insurers about the possibility of compensation for a trauma team fee.
Will the legislature be on board, knowing that state dollars are helping pay doctors, who many people believe are compensated well enough? State Rep. Gene Shelby of Hot Springs, who helped author the trauma system legislation, says the legislature will be keeping a close eye on things. As a doctor himself, he understands the problems of supply and demand in emergency rooms and the need for recruitment dollars. “In Hot Springs we have fewer general surgeons than 10 or 15 years ago.” The average age of general surgeons in Arkansas is 59, Shelby said; many have retired, and are not being replaced, since younger surgeons are specializing. That leaves emergency departments in a bind. Shelby's own hospital, National Park, ironically, did not apply to be part of the trauma system. “A lot of hospitals are kind of nervous about how much increase in trauma patients is going to occur.”
Notably absent from the trauma system is Washington Regional Hospital in Fayetteville, second in size only to Sparks Regional (Fort Smith) in Northwest Arkansas. Spokesman Terry Fox said that participation in the system is still being discussed internally.
There are a number of hospitals along the Fayetteville-Springdale-Rogers corridor, making the market competitive. Some have suggested that Washington's management may fear that if it becomes a trauma center, its share of trauma patients will increase. Mercy Medical in Rogers was approved as a Level 3.
Several hospitals in Northwest Arkansas have been approved as Level 4 hospitals, which are required to have an emergency department, on-call physicians qualified to care for patients with traumatic injuries and in-house registered nurses with training in emergency care, along with necessary medical devices.
Despite what some at the legislature feared, the trauma system is not about funneling money to UAMS, the Health Department Director Halverson said. “The strength of the system will be in levels 2 and 3.” Five hospitals have applied for Level 2 designation; 20 have applied for Level 3. Twenty-nine have applied for Level 4.
Jefferson Regional in Pine Bluff ? which serves all of South Arkansas and has the highest percentage of uncompensated care in the state at 30 percent ? will use a portion of its Level 2 readiness grant to help offset the cost of on-call pay.
In January, Jefferson instituted for the first time on-call pay for its neurosurgeon and orthopedic surgeons.
Around-the-clock availability is “a real burden for trauma surgeons,” Chief Executive Officer Bob Atkinson said. Surgeons who are called to the OR in the middle of the night for emergency procedures may have to cancel their scheduled (and paid) surgeries the following day. “It's appropriate for [trauma dollars] to pay for some on call,” he said.
The grant may help in recruitment of doctors as well, he said.
JRMC's ER has some 50,000 visits a year, Atkinson said.
Like Jefferson Regional, White River Health System in Batesville is also implementing paid call, and would use part of its grant for that. A Level 3, White River will also use a portion of its grant to buy software to track trauma patients, pay a trauma coordinator and do preventive education in the community. White River Health sees around 31,000 in its emergency department yearly, chief nursing officer Dede Strecker said.
But North Arkansas Regional Medical Center in Harrison, also a Level 3, will not buy call coverage. Tim Hill, until October CEO of the hospital (he's taking a job as president and CEO of the Heart Hospital), said trauma dollars at the hospital will be used to “enhance services.”
North Arkansas sends its major trauma cases to Springfield, to St. John's or CoxHealth. “It's a challenge to ER physicians and staff to find a receptive hospital that has capacity,” Hill said.
White County Medical Center in Searcy, which treats between 30,000 and 35,000 patients through its emergency department and has applied for a Level 3 designation, will use its subgrant to “infrastructure” ? computers and communication, CEO Ray Montgomery said.
Level 3 requires an ER to have surgeons on-call and promptly available as well as other trauma-care capabilities and equipment.
Will maintaining its Level 3 designation cost White County more than the grant will cover? “Probably,” Montgomery said. “Until we get into it, we won't know.”