New adult trauma center on Chicago’s South Side will treat violence as a disease

Closing a more than quarter-century gap in trauma care on the South Side of Chicago, IL, the University of Chicago Medicine (UCM) is building a Level 1 adult trauma center, part of a new and expanded emergency department (ED), which is expected to cut travel time to surgery by 50 percent.^1,2

The call for an adult trauma center at the university gained momentum in 2010 after the death of drive-by shooting victim Damian Turner. Mr. Turner, 18 years old, was shot three blocks from UCM, but died en route to Northwestern Memorial Hospital’s adult trauma center located on the Near North Side of Chicago.^3,4 The South Side of Chicago has been without an adult trauma center since 1991.

Selwyn O. Rogers, Jr., MD, MPH, FACS, formerly chief medical officer, University of Texas Medical Branch, Galveston, will lead the development of the new adult trauma center, which is scheduled to open in spring 2018. Dr. Rogers, a public health expert and chief, section for trauma and acute care surgery, UCM Trauma Center, has acknowledged the challenging history between UCM and the South Side of Chicago, and is focused on specifically addressing the health care needs of the underserved communities in the area.

This article describes the state-of-the-art development of UCM’s new ED and adult trauma center—which will feature an efficient design plan to reduce wait, admission, and discharge times—and to identify how this center could be a model for adult trauma program expansion in other urban areas.

A demonstrated need for the new ED/adult trauma center

The number of adult visits at UCM’s current ED, built in 1983, continues to increase, according to UCM administrators, and would fail to meet the needs of the community without this expansion. From 2009 to 2016, adult ED visits grew from 39,000 to more than 59,000.⁵ In addition, as many as 6,000 patients choose to leave UCM’s ED each year without being seen because of excessive wait times.⁶ The new ED will be 76 percent larger (29,017 square feet versus 16,517 square feet) than the present structure and will accommodate more patients and their care more efficiently.⁶

The UCM adult trauma center will be one of five such centers in Chicago, including Stroger Hospital (formerly Cook County Hospital) and Mount Sinai on the West Side, Northwestern Memorial Hospital, and Advocate Illinois Masonic Medical Center on the North Side. Other Level 1 adult trauma centers in Cook County are in the suburbs of Oak Lawn, Maywood, Park Ridge, and Evanston. Patients who are critically injured on the South Side of the city, as was the case with Mr. Turner, are routinely taken to centers that are far from the point of injury to receive adult trauma care.

A study published in the June 2013 issue of the American Journal of Public Health revealed relative “trauma deserts” in certain areas of Chicago, which “adversely affected mortality from gunshot wounds,” particularly for patients who have longer transport times.⁷ Specifically, patients shot more than five miles from a trauma center (trauma deserts) were 23 percent more likely to die. The study was intended, in part, to “inform decisions about trauma system planning and funding” and the new UCM adult trauma center will likely help to alleviate the trauma desert problem in this Chicago neighborhood.⁷

“I think it can be a difficult concept for those not involved within the region to see what the transport patterns are,” said Richard J. Fantus, MD, FACS, chairman of both the Chicago region trauma center medical directors committee and the Illinois Department of Public Health (IDPH) State Trauma Advisory Council. “But I think that there will be a benefit, ultimately, to patients in those nearby communities because [the UCM trauma center] will shorten transport time.”

Dr. Fantus also noted that trauma system development in Illinois has been affected by the geographic location of existing institutions. “Unlike Starbucks franchises, where you are able to go out and assess the market, and you are able to place them geographically in the exact location that would handle the population, large centers that actually have the capacity to be Level 1 facilities are restricted based on where they are currently located. Even with the increase in trauma volume the region experienced last year, there is still an excess capacity at the existing trauma centers to handle those patients. This situation is more about the geographic disparity of the existing locations of the individual centers,” Dr. Fantus said.

Door-to-doctor design enhances patient experience

UCM’s new ED, a build-out that is expected to require a $39 million investment, will have 11 more treatment stations than the existing ED and four new trauma resuscitation bays, in addition to imaging facilities, a rapid assessment unit for patients with minor medical conditions, and an on-­‐site biocontainment unit to treat patients with infectious diseases.

“I think one of the unique features of how we designed our ED was having detailed input from the people on the ground—including our physicians, nurses, technicians, environmental services, transporters, radiologists—everyone who plays a role in the care of patients in the ED,” said Linda Druelinger, MD, section chief, emergency medicine, UCM.

“The staff input, to Dr. Druelinger’s point, from the frontline clinicians who are actually working in the environment and making the decisions was important in determining what this new environment will look like and how patient flow can be maximized,” explained Vikas Ghayal, executive director, patient care operations, UCM. “We followed the Lean methodology, which means that for the last four years, we conducted week-long, very structured process improvement (PI) events called ‘kaizens’ facilitated by a trained Lean professional to gather input from the clinicians.” According to Mr. Ghayal, these PI events included approximately 240 hours devoted to generating a design plan for the ED.

When completed, the new ER will have 33 treatment rooms, including four psychiatric rooms, 12 internal waiting areas, and one bariatric room. Another key feature of the revamped ED is the placement of computed tomography (CT) scanners in close proximity to the trauma resuscitation bays. Additionally, the ED will be much closer to the critical care beds, interventional radiology, and all of the key resources required to provide optimal care to these patients, Dr. Druelinger noted.

“With the addition of the trauma center—and redesigning the floor plan to incorporate the trauma resuscitation rooms—we had the good fortune of being able to partner with Dr. Rogers for his input,” Dr. Druelinger added. “We designed a very open space—our ambulance entrance will lead directly from the ambulance bay, a quick straight shot into our trauma bays. With this open concept, we can visually see patients and attend to their needs,” she said.

“Right now, it can take close to 20 minutes to get from our current ED space to the operating room (OR),” Mr. Ghayal added. “Moving into the new ED, we are going to be right next to the Center for Care and Discovery, and we should be able to get to the OR within seven to 10 minutes, which is how we’ve timed it when we’ve walked it ourselves.” The new ED will be connected to the Center for Care and Discovery hospital, located on the UCM campus, which will allow efficient access to lifesaving care via the OR.

“From a through-put standpoint, getting patients in and out of the department—there is a lot that the ED physicians and nursing leadership team have done during the last couple of years to look at patients coming in and out of our department and determine ways of removing waste while creating value-added steps to the care process,” Mr. Ghayal said. “What we are currently seeing with the different processes that we have put in place is that we are able to shave off an hour’s length of stay per patient.”

“A lot of EDs across the country are starting to use a model where they put a physician in the triage area to improve door-to-doctor time,” Dr. Druelinger explained. “As soon as the physician sees the patient, we can get a brief, directed history and we can actually implement orders for tests that the patient is going to need, enabling the nurses to begin acting on those orders pretty quickly.”

Adequate staffing is another way UCM administrators intend to improve door-to-doctor time. At press time, UCM had hired eight faculty members to augment the existing roster of 20 faculty members, with a goal of bringing in five more faculty members before the center opens in 2018, according to Dr. Druelinger.

“Our intention is to provide adequate faculty supervision of house staff and adequate faculty to care for patients as well,” Dr. Druelinger explained. “Working with Dr. Rogers, we’re determining how we’ll partner together to care for the trauma patients when they present in the ED.”

In fact, Dr. Rogers is currently building an interdisciplinary team of specialists to treat patients suffering from life-threatening trauma. “We have to recruit trauma faculty who will be key leaders, but really adequate staffing is about teams and identifying all the current gaps of where we are now and where we need to be to be an American College of Surgeons [ACS]-verified trauma center,” Dr. Rogers said.

Designated trauma center

A facility earns the title of “designated trauma center” when it meets the requirements of the government or other authorized entities. At press time, the IDPH, a state agency, is in the process of verifying these requirements for the UCM adult trauma center. The ACS does not designate trauma centers—the ACS Committee on Trauma confirms that a trauma center has the necessary resources for delivering optimal trauma care as outlined in the guidebook Resources for Optimal Care of the Injured Patient.⁸ To determine if a hospital meets ACS trauma center standards, a team of trauma experts completes an on-site review of relevant features of the facility’s trauma program. The review examines components including commitment, readiness, resources, policies, patient care, and performance improvement.⁸

“Our goal is to be accredited by Illinois when we open, and then, within three years, to get the ACS accreditation,” Mr. Ghayal said. “Right now, we are focusing on having the appropriate faculty in place and getting Dr. Rogers in a position to build his team. We’re starting to put the pieces together with people who have done this before who understand the trauma world, which will really help as we develop our processes and pursue Level 1 accreditation.”

“Even after we open next year, we know we’re going to be on a continuous quality improvement journey,” Dr. Rogers added. “And we will embrace that and continue to work toward a culture of social justice and equity.”

The new and expanded ED at UCM is projected to treat an additional 25,000 patient visits a year by 2021, according to hospital administrators, and approximately 2,700 adult trauma patients are expected in the first 12 months after the facility is approved for Level 1 trauma care.¹

Public health expert, trauma surgeon provides leadership

Dr. Rogers began working in his new role in January. Since then, he’s been developing policies to support the kind of cultural transformation that needs to occur at an institution that has functioned without an adult trauma center for nearly three decades. “UCM is an exceptional academic health center that performs a wide range of complex surgical services, like organ transplantation and cancer care,” Dr. Rogers said. “However, trauma care requires integration of all services of a hospital working seamlessly together for the care of the traumatized patient. That system of care alters the cadence of a hospital, including providing a multitude of services during the nights and weekends when most elective surgery is long over.” Dr. Rogers also underscored the need for quality assessment to ensure continuous quality improvement—systems he said “need to be actively in place before we open next year.”

“I think Dr. Rogers brings a wealth of experience and knowledge that’s needed to really get this program up and running,” Mr. Ghayal said. “It’s unique for an academic facility to go from no trauma designation on the adult side to a Level 1 trauma center, and there are a lot of things that we have to do to help support that throughout the organization. Having Dr. Rogers here to walk us through that process, to be the voice of reason, and really help explain all the different aspects that trauma affects, from an organization-wide standpoint, is critical.”

In addition to his leadership role at the University of Texas Medical Branch, Dr. Rogers served as chair, department of surgery, and surgeon-in-chief, Temple University Hospital, Philadelphia, PA, from 2012 to 2014, and as division chief of trauma, burn, and surgical critical care, Brigham and Women’s Hospital and Harvard University School of Medicine, Boston, MA, from 2005 to 2012.⁹

Dr. Rogers brings 16 years of trauma care leadership experience to his role at UCM, but he also brings a clinical and research background focused specifically on the health care needs of underserved populations.⁹ At Harvard, Dr. Rogers helped to launch the Center for Surgery and Public Health, with the mission of advancing the science of surgical care delivery by studying effectiveness, quality, equity, and value at the population level and of developing surgeon-scientists committed to excellence in these areas. Building on his interest in serving marginalized communities, Dr. Rogers was appointed to the role of executive vice-president for community health engagement at UCM.⁹ In this capacity, Dr. Rogers and his team will work to develop programs and leverage the resources of the medical center and the university to improve the health of neighboring communities on the South Side.

Dr. Rogers said he intends to launch a “listening tour,” visiting community centers, churches, and other public venues to learn how the new ED and trauma center at UCM can better serve the local community. He said he feels a “sense of urgency” to respond to the level of gun violence in Chicago, and on the South Side in particular. He noted that building ongoing, permanent relationships with members of the community will be key to stemming the gun violence epidemic.

“A big part of my role—in addition to setting up a Level 1 trauma center—is community engagement,” Dr. Rogers said. “I want to learn from the community, the perspectives and challenges of its members, and to find opportunities to create partnerships. I think this is critical in addressing intentional violence and gun violence. How can we possibly fix a problem, if we don’t get close to a problem? At the University of Chicago Medicine, we’re not simply waiting for the trauma to happen and then reacting to it,” he said.

Treating the root causes

Dr. Rogers is keenly aware of the importance of responding to the underlying causes of violence rather than focusing on the violence itself. For him, it’s a personal issue that began one night when he was a junior faculty member at Brigham and Women’s Hospital.

“This particular night I was on call, a 28-year-old African-American man came in who had been shot in the back of the head, and it was pretty clear that he was brain dead from the initial exam. There was no brain activity, but he still had a pulse and he still had blood pressure. As we waited for the family to arrive, I found myself struggling with how to explain brain death. It’s not a concept everyone is familiar with, and there are cultural and religious beliefs that support the idea that if the heart is beating and blood is flowing then the individual is still alive. So, I was trying to work through my mind, what analogy, what approach, should I use to explain to this mother what brain death was,” Dr. Rogers said.

When the victim’s mother and his young daughter arrived in the intensive care unit, the mother listened attentively to Dr. Rogers’ explanation of her son’s situation. The mother’s demeanor remained self-contained, and she responded by asking if her son’s daughter (her granddaughter) could see him one last time.

“So, I prepared them both the best that I could. I told them the son would be sleeping, that he would have a tube in his mouth, and that they could touch him if they wanted to and that he’d feel warm but he wouldn’t react. A short time later, the young girl was ushered into the room, and she reached out and touched her dad’s hand. The mother was very resolute and focused, and to me, it was a very powerful moment. And in the end, I was very emotionally torn up inside, but I had enough courage to ask the mother, ‘What is the source of your strength?’”

Dr. Rogers said he expected the mother to say her source of strength was her faith or God’s will, but her response was none of those things.

“Her response was more chilling. She very calmly said, ‘I had to do this for my other son two years ago.’ This was her second child who had died after being shot in the head. That day, I committed to the idea that we have to do more than just take care of people when they come in. As health care providers, we have to address the social determinants of this disease of violence in our communities and think about the structural things that put people at risk and then modify those risks,” Dr. Rogers said.

“One of the things that excites us about Dr. Rogers being here is the whole violence prevention component that he has experience in and is wanting to implement within the University of Chicago,” Mr. Ghayal said. “Our goal really is to develop a trust with the community to get to the root causes of some of these traumas and to provide the resources that are needed to stem the violence that is happening. I think our vision has always been that a trauma center is not the answer to the violence that is happening in Chicago or anywhere. It is a component to support the community, but you need an intentional program to help facilitate conversations and provide the necessary resources.” Modifying those risks and preventing the deaths they cause will be the driving principle that Dr. Rogers will apply at UCM’s new adult trauma center.

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References

1. University of Chicago Medicine. New emergency department with adult trauma care fact sheet. September 15, 2016. Available at: uchicagogetcare.org/2016/09/15/new-emergency-department-with-adult-trauma-care-fact-sheet/. Accessed April 5, 2017.
2. Davey M. Center to give trauma care on South Side of Chicago. New York Times. September 11, 2015. Available at: www.nytimes.com/2015/09/12/us/center-to-give-trauma-care-on-south-side-of-chicago.html?_r=0. Accessed April 4, 2017.
3. Bishku-Aykul J. Why put trauma centers where no one gets shot? The Nation. April 29, 2015. Available at: www.thenation.com/article/why-put-trauma-centers-where-no-one-gets-shot/. Accessed May 1, 2017.
4. Kirsch C. Trauma head announced. The Chicago Maroon. January 12, 2017. Available at: www.chicagomaroon.com/article/2017/1/12/trauma-center-head-announced/. Accessed March 30, 2017.
5. Ihejirika M. U of C Medicine breaks ground on emergency room trauma center. Chicago Sun-Times. September 15, 2016. Available at: chicago.suntimes.com/news/u-of-c-medicine-to-break-ground-on-emergency-room-trauma-center/. Accessed April 5, 2017.
6. University of Chicago Medicine. New emergency department: Frequently asked questions. Available at: www.uchospitals.edu/pdf/uch_048088.pdf. Accessed April 3, 2017.
7. Crandall M, Sharp D, Unger E. Trauma deserts: Distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. Am J Public Health. 2013;103(6): 1103-1109.
8. American College of Surgeons. Verified trauma centers FAQs. Available at: facs.org/quality-programs/trauma/vrc/faq. Accessed April 12, 2017.
9. University of Chicago Medicine. Dr. Selwyn Rogers to head UChicago Medicine’s adult trauma center. January 12, 2017. Press release. Available at: www.uchospitals.edu/news/2017/20170112-rogers.html. Accessed April 5, 2017.