Committee on Trauma introduces needs assessment tool aimed at resolving trauma center debate

A total of 428 U.S. trauma centers have been surveyed and verified by the American College of Surgeons (ACS), which means the College has confirmed the presence of support mechanisms as outlined in the Resources for Optimal Care of the Injured Patient at these facilities.* In recent years, there has been intense controversy surrounding the number of trauma centers that should be available in a given region, their level of designation, and the designation process. One side argues that trauma centers, especially Level II institutions, have proliferated at an uncontrolled pace. The individuals on this side of the debate argue that this lack of restraint has resulted in an oversupply of care in specific areas, increased spending, and enhanced competition between centers, thereby destabilizing the system as a whole. Individuals on the other side of the debate maintain that the new centers fill a perceptible community need and that the decision for a hospital to become a trauma center is the prerogative of the individual institution. According to the individuals who hold this view, any hospital capable of meeting the standards should be free to pursue trauma center designation.

To assist in resolving this debate, the ACS Committee on Trauma (COT) has taken two significant steps in recent years: (1) released a position statement on trauma center designation, and (2) developed a new instrument to measure the trauma center needs of the various regions in the U.S. This article focuses largely on this tool—the ACS Needs Based Assessment of Trauma Systems (ACS NBATS).

COT position statement

In 2014, the ACS COT developed and the ACS Board of Regents approved a Statement on Trauma Center Designation Based upon System Need, which was published in the January 2015 Bulletin. In this statement, the College makes the following assertions: the designation of trauma centers is the responsibility of the lead state or county-level agency; the distribution of trauma centers should be guided by a regional plan based on the needs of the populations served, with health care providers advocating for the collective interests of patients served; and that system needs to be assessed using objective measures of trauma system access, quality of care, trauma-related mortality rates, and system efficiencies. Although the importance of controlling the allocation of trauma centers by the lead governmental entity based on regional population need has been recognized since the 1980s, few trauma systems have been able to meet the criteria outlined in the ACS COT statement. Therefore, trauma system designation has been driven by individual institutional priorities, and timely access to trauma care has fluctuated with the economic tide. The authors of the statement called for an international group of experts, stakeholders, and policymakers to convene and plan for optimal future regional trauma system development.

Needs Based Trauma Center Designation Consensus Conference

In August 2015, the ACS COT convened the Needs Based Trauma Center Designation Consensus Conference. A broad group of stakeholders involved in the establishment, operation, and designation of trauma centers throughout the U.S. attended the meeting, which featured representatives of national professional organizations, including emergency medicine, prehospital professionals, and surgeons, as well as administrators from individual trauma centers, regional advisory councils, state health and hospital departments, and the national U.S. Department of Homeland Security and U.S. Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (see Table 1). The goal of this conference was to review the principles outlined in the ACS COT statement and to begin work on a set of practical methods and metrics to determine a needs based designation of trauma centers that would be broadly accepted.

Table 1. Needs Based Trauma Center Designation Consensus Conference participants

Participant Title (at time of conference) Affiliation

Maria Alvi, MHA

Manager, Trauma Systems and Quality Programs

ACS Trauma Programs

John H. Armstrong, MD, FACS

Florida Surgeon General and Secretary of Health

Florida Department of Health

Jane Ball, RN, DrPH

ACS Trauma Consultant

ACS Trauma Programs

Betty J. Bartleson, MSN

Vice-president, nursing and clinical services

California Hospital Association

Brendan G. Carr, MD, MA, MS, FACS

Director of Emergency Care Coordination Center, Division of Health System Policy

U.S. HHS; Office of the Assistant Secretary for Preparedness and Response

Eric Chaney, MBA

Representing the Deputy Director (Acting), Workforce Health and Medical Support Division

U.S. Department of Homeland Security

Jean Clemency

Administrative Director

ACS Trauma Programs

Matt Coffron, MA

Manager, Policy Development

ACS Division of Advocacy and Health Policy

Drew Dawson

Director, Office of Emergency Medical Services

National Highway and Traffic Safety Administration (NHTSA)

Beth Edgerton, MD, MPH

Director, Division of Child, Adolescent and Family Health (DCAFH)

HHS Health Resources and Services Administration (HRSA)

Eric Epley

Executive director

Southwest Texas Regional Advisory Council;
Regional Structure

Robert Fojut

Editor

Trauma System News

Robert Gfeller

Executive director

Childress Institute for Pediatric Trauma

Cathy Gotschall, ScD

Senior health scientist

NHTSA

Robert Jex, RN

Specialty Care Program Manager

Utah Department of Health, Bureau of Emergency Medical Services; Utah Office of Rural Health

Chuck Kearns, MBA

President

National Association of Emergency Medical Technicians

Molly Lozada

Manager, Trauma Centers Quality Verification, Review,
and Consultation Program for Hospitals

ACS Trauma Programs

Ellen Mackenzie, PhD

Fred and Julie Soper Professor and Chair

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Robert Mackersie, MD

Professor of surgery and director of trauma services

University of California, San Francisco; San Francisco General Hospital and Trauma Center

Dennis Maier, MD

Medical director

Surgical Associates, PC

Charles W. Mains, MD, FACS

General surgeon

Surgical Specialists of Colorado

N. Clay Mann, MS, PhD

Professor of surgery

NEMSIS TAC PI, University of Utah

Gregg S. Margolis, PhD, NRP

Director, Division of Health System Policy

HHS Office of the Assistant Secretary for Preparedness and Response

Scott Matthews

Graphic recorder, company co-founder

Tremendousness

Robert T. Maxson, MD, FACS

Pediatric surgeon

Arkansas Children’s Hospital

Melanie Neal

Manager, National Trauma Data Bank

ACS Trauma Programs

Debra Perina, MD, FACEP

Director

American College of Emergency Physicians, National Association of Emergency Medical Services Physicians

Justin Rosen

Congressional Lobbyist

ACS Division of Advocacy and Health Policy

Nels D. Sanddal, PhD, REMT

Manager, Trauma Systems and Trauma Center Verification Programs

ACS Trauma Programs

Ronald M. Stewart, MD, FACS

Chair, COT

ACS Trauma

Leonard J. Weireter, MD, FACS

Vice-Chair, COT

ACS Trauma

Eileen Whalen, MHA, RN

President and chief operating officer; acting chief nursing officer

University of Vermont Medical Center

Robert J. Winchell, MD, FACS

Chair

ACS Trauma Systems Evaluation and Planning Committee

Michele Ziglar, RN, MSN

Vice-president, trauma services

Hospital Corporation of America

This diverse group of attendees unanimously supported the concept that trauma center designation within a regional trauma system should be based on the needs of the population served, as outlined in the ACS position statement. The consensus group also unanimously endorsed each of the ACS COT Principles for Trauma Center Designation outlined in Table 2. Furthermore, meeting attendees confirmed the immediate need for a practical tool that draws from existing data and can be used to assist regions that are struggling with the issue of new trauma center designation.

Table 2. ACS COT Principles for Trauma Center Designation

  • Trauma center designation within a regional trauma system should be based on the needs of the population served.
  • The best interests of the population served should be held above the interests of stakeholder groups.
  • Trauma centers and stakeholders within a region have a duty to work together cooperatively to achieve the first two goals, even in the face of competition.
  • The role of the academic Level I trauma center is important to patient care and system function and should be actively preserved by those in the system.
  • A practical tool should be developed, based upon currently available data, that can be used to assist regions currently struggling with the issue of new trauma center designation.

The group collaborated on the development of a tool to assist administrators from various regions in performing a needs assessment and determining the number of trauma centers required to meet patient demand. The conference workgroup was fully cognizant of the challenges involved in this process, not the least of which is a lack of proven metrics that accurately evaluates need. Ultimately, the group determined two goals in developing this tool: (1) to produce a pragmatic and relatively simple instrument that would be based on presently available data, and (2) to start a process that would lead to future improvements and refinements in the approach.

ACS NBATS

The final product—the ACS NBATS tool—is designed to evaluate the need within a particular geographic area, termed a trauma service area (TSA). A TSA can range in size from a small county to a multistate region, and from several thousand to several million people. The assessment tool evaluates the number of centers needed within the TSA, starting from a clean slate and then making adjustments for existing trauma centers (Level I, II, and III) in the TSA. The ACS NBATS tool does not specifically assess the impact of adding an additional center to a TSA, nor does it determine the relative merit of a particular facility becoming a trauma center within the TSA.

The group drafted ACS NBATS (see Table 3), working from a model first applied in Florida. The group chose this approach because it incorporates the critical data elements that have been considered in other system benchmarking efforts and represented a reasonable starting point. Although the Florida model provided the initial backbone for the ACS NBATS tool, the group intended to use it purely as a starting point and did not seek to recreate the Florida experience with this system.

Table 3. ACS NBATS Tool

1. Population

  • Total TSA population of less than 600,000: 2 points
  • Total TSA population of 600,000–1,200,00: 4 points
  • Total TSA population of 1.2 million–1.8 million: 6 points
  • Total TSA population of 1.8 million–2.4 million: 8 points
  • Total TSA population of greater than 2.4 million: 10 points

Points assigned:         

2. Median transport times (combined air and ground—scene only, no transfer)

  • Median transport time of less than 10 minutes: 0 points
  • Median transport time of 10–20 minutes: 1 point
  • Median transport time of 21–30 minutes: 2 points
  • Median transport time of 31–40 minutes: 3 points
  • Median transport time of greater than 41 minutes: 4 points

Points assigned:         

3. Lead agency/system stakeholder/community support

Lead agency support for a trauma center (if none exists) or an additional trauma center in the TSA: 5 points

Trauma System Advisory Committee (or equivalent body) statement of support for a trauma center (if none exists) or an additional trauma center in the TSA: 5 points

Community support demonstrated by letters of support from 25 percent to 50 percent of city and county governing bodies within the TSA: 1 point

Community support demonstrated by letters of support from more than 50 percent of city and county governing bodies within the TSA: 2 points

Points assigned:         

4. Severely injured patients (injury severity score [ISS] > 15) discharged from acute care facilities not designated as Level I, II, or III trauma centers

  • Discharges of 0–200 severely injured patients: 0 points
  • Discharges of 201–400 severely injured patients: 1 point
  • Discharges of 401–600 severely injured patients: 2 points
  • Discharges of 601–800 severely injured patients: 3 points
  • Discharges of greater than 800 severely injured patients: 4 points

Points assigned:         

5. Level I Trauma Centers

  • For the existence of each verified Level I trauma center already in the TSA: –1 point
  • For the existence of each verified Level II trauma center already in the TSA: –1 point
  • For the existence of each verified Level III trauma center already in the TSA: –0.5 points

Points assigned:         

6. Numbers of severely injured patients (ISS > 15) seen in trauma centers (Level I and II) already in the TSA

      The expected number of high-ISS patients is calculated as:

500 x (number of Level I and Level II centers in the TSA) =           

  • If the TSA has more than 500 severely injured patients above the expected number: 2 points
  • If the TSA has 0–500 severely injured patients above the expected number: 1 point
  • If the TSA has 0–500 fewer severely injury patients than the expected number: –1 point
  • If the TSA has more than 500 fewer severely injured patients than the expected number: –2 points

Points assigned:         

The following scoring system shall be used to allocate trauma centers within the TSAs:

  • TSAs with scores of 5 points or less shall be allocated 1 trauma center
  • TSAs with scores of 6–10 points shall be allocated 2 trauma centers
  • TSAs with score of 11–15 points shall be allocated 3 trauma centers
  • TSAs with scores of 16–20 points shall be allocated 4 trauma centers

If the number of trauma centers allocated by the model is greater than the existing number of trauma centers in the TSA, efforts should be undertaken to recruit and designate additional trauma centers.

If the number of trauma centers allocated by the model is less than the number of existing trauma centers, the lead agency should not designate additional trauma centers in the TSA.

The ACS NBATS assigns points based upon four elements: population, transport time, community support, and the number of severely injured patients discharged from centers in the TSA that are not Level I, Level II, or Level III trauma centers. This raw score is then adjusted based upon the number of existing Level I, Level II, and Level III centers and the volume of severely injury patients who receive care at those existing centers. The final score provides a guideline for the number of trauma centers needed in the TSA.

The conference participants acknowledged that no clear evidence is available to support the use of any of the specific measures proposed, and, as a result, all recommendations reflect the expert opinion of the convened group, as derived through a deliberative process. The tool itself, along with point assignments for each element and the point totals to determine trauma center need in this draft, are for initial evaluation purposes only. It is anticipated that both the individual element scores as well as the final target ranges will vary depending upon the demographics of the particular TSA (population, population density, size, geography, and so on) and will reflect the balance of priorities within the specific trauma system.

Next steps

The ACS COT has endorsed the operational principles summarized in Table 1 as tenets of optimal trauma system function. The ACS NBATS tool is being circulated to a larger audience of stakeholders and groups involved in the trauma center designation process for comment and for initial testing in a range of existing systems in an effort to validate this system and to collect data that can be used to improve and refine the tool. The ACS COT also is working with a handful of states and regions to test the utility of the tool and application of the model with the intent of refining data elements, benchmark levels, and the relative weight of the individual elements to provide the best model performance. It is anticipated that this will be an iterative process. Data collection and analysis is currently under way, and a summary report and version updates are planned by the time of the spring COT meeting in March 2017.

The consensus group is seeking regions willing to participate in the process of analysis and refinement and is seeking stakeholder feedback on the ACS NBATS tool. Contact Maria Alvi, Manager, Trauma Systems and Quality Programs, for additional information or to become part of the evaluation process. An feedback form is available online.

At press time, a follow-up meeting of the consensus group was scheduled to convene this year to continue the work of refining the tool and to expand pilot testing.


*American College of Surgeons. Searching for verified trauma centers. Available at: facs.org/search/trauma-centers. Accessed July 8, 2016.

American College of Surgeons Committee on Trauma. American College of Surgeons Trauma Center Search 2016. Available at: facs.org/search/trauma-centers?country=United%20States. Accessed July 8, 2016.

American College of Surgeons’ Committee on Trauma. Statement on trauma center designation based upon system need. Bull Am Coll Surg. 2015;100(1):51-52. Available at: bulletin.facs.org/2015/01/statement-on-trauma-center-designation-based-upon-system-need/. Accessed July 8, 2016.

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