Nation's Trauma & Emergency System Nears Breaking Point
Congress is currently considering two pieces of legislation that many leaders in trauma care and emergency medicine consider a lifeline for their respective specialties. Without intervention, these professionals fear a time will come when a call for emergency care cannot be answered.
Connie Potter, RN, MBA, MHA, president of the Trauma Center Association of America (formerly the National Foundation for Trauma Care), said emergency and trauma medicine couldn't continue on the current trajectory, and the recent economic downturn only makes matters more precarious for facilities that are teetering on the brink of closure.
She noted there were 20 closures among trauma centers and 13 downgrades in a five-to-six year period at the beginning of this decade. A 1994 survey found trauma centers were losing 8 percent of costs. "For every $1 spent on trauma care, they received 92 cents," she said. "We repeated that study in 2004 with a government grant … and lo and behold, we had slipped to 14 percent so for every $1, they received 86 cents. If you're a Burger King, and you are selling a burger for 86 cents that costs a $1 to make, how long are you going to be able to stay open?"
Emergency departments aren't in any better shape. James Eadie, MD, a spokesperson for the American College of Emergency Physicians (ACEP), noted there were 119.2 million visits to emergency departments in 2006, which represented a 32 percent increase in traffic compared to 1996. "We've had a 30 percent increase in utilization. While at the same time over that decade," he continued, "we saw a decrease in the number of emergency departments by 186 … or 5 percent."
Eadie added, "We want to intervene before the emergency department needs life support. It's overburdened, under funded and highly fragmented."
National Trauma Center Stabilization Act of 2009 (S 733/HR 936)
This bill would provide federal funding ($200 million in Senate version and $125 million in the House legislation) to assist trauma centers with uncompensated care, core mission services and emergency needs.
"Eisenhower understood way back in the 50s that to move military vehicles we needed better than our two lane roads," Potter said, drawing an analogy to our current trauma system. "We have yet to see a trauma patient that will stop at a border … including our U.S. border. We cannot just put it (care) in little silos and tell each state to take care of their own."
She continued, "Our overarching goal is that anywhere you're injured in this country, you'll have access to a trauma center, and … should you need it … be transferred rapidly in a pre-planned manner to the highest level trauma center necessary."
The first $100 million in provisions are nearly identical in the Senate and House versions. This portion of the legislation is divided into three sections: $20 million would be set aside for the core mission of each trauma center such as administrative costs; $70 million is earmarked for unfunded care compensation; and $10 million is set aside to provide temporary assistance to distressed trauma centers that are on the brink of closing … or, if they do close, to help other hospitals in the region develop a trauma program. In each of these sections, 75 percent of the funding is designated for Level I and Level II trauma centers with 25 percent earmarked for Level III and Level IV centers.
The additional $100 million in the Senate version is a grant program to develop new trauma centers or consortiums of hospitals and trauma centers. States would receive $20 million to administer the grants with the balance being available to upgrade capacity and technology, hire trauma specialists, and to make capital acquisitions and other necessary infrastructure investments. The additional $25 million in the House version is for the development and maintenance of innovative information technology systems with an eye toward communication in times of natural disaster, pandemic or acts of terrorism.
"This is the second reintroduction of this bill," Potter noted. "It's been authorized and never appropriated." She added that whereas this legislation was primarily an urban bill in the past, its current iteration is much broader and an integral part of healthcare reform, which she hopes will help the legislation pass and be funded.
To do nothing is no longer an option. "These hospitals are the linchpin of our national disaster infrastructure whether we know it or not," she pointed out. "It (trauma care) needs to be there ever vigilant, ever present, ever ready."
Access to Emergency Medical Services Act of 2009 (S 468/HR 1188)
"The emergency rooms and emergency departments are really at the foundation and core of our healthcare delivery system," said ACEP spokesperson James Eadie, MD, who is a board certified emergency medicine physician.
Unfortunately, he continued, we cannot take for granted that care will always be there in every community. Eadie pointed to a landmark 2006 Institute of Medicine study that found our nation's emergency medical system to be highly fragmented and at the breaking point. In December 2008, ACEP released a National Report Card on the State of Emergency Medicine which assigned a D- nationwide in terms of access to emergency care.
Eadie said there are three key parts to the bipartisan legislation, which attack the issues facing emergency care from different vantage points. The first, he said, is to bring stakeholders to the table by establishing a national commission on access to emergency medical services to examine factors affecting the delivery of care in emergency departments.
"Two," he continued, "is we recognize one of the challenges at this point of providing emergency services is having on-call specialists to be responsive 24/7 for emergency medicine so the bill looks to provide financial incentives to physicians and hospitals who provide emergency and trauma care to Medicare patients." Eadie added, "Many rural and even large cities lack critical specialists to adequately provide care."
He continued, "The third prong of the bill is to work with CMS to develop hospital boarding and diversion standards." Eadie noted boarding is unfortunately a national phenomenon that leads to a vicious cycle of backlog with patients sitting in a waiting room while others take up beds in the emergency department because they are waiting for an inpatient room.
"We see it every day," Eadie said of emergency medicine physicians around the country. "Families thinking, 'we're not in a developing world – this can't be happening in the emergency department in America.'"
Yet it is happening. Eadie continued, "What the IOM identified is that due to overcrowding … primarily driven by boarding … that ambulances are diverted from hospitals at a rate of one a minute, 365 days a year. Every minute of every day, an ambulance is told 'please do not come here … we don't have the resources to take care of that patient.'"
Originally introduced in 2007, the bill received a lot of verbal support but didn't make it out of committee. In today's reform climate, Eadie feels more hopeful about the chances of this legislation – which is the same in both the House and Senate versions – getting serious attention. He added that Representatives Bart Gordon (D-TN) and Pete Sessions (R-TX), who cosponsored the House version, have been real champions for this issue and long-time advocates for emergency services in America.
"We inherently have this huge trust, both as a medical profession and as the American population, that the emergency system will always be there for us in our time of need," Eadie stated. "What the IOM has said is that safety net … that foundation of our medical care … is at a fracturing point. We must act now. We do not have the time to allow the system to crumble any further."