18HoffandSchwab
TABLECampaigns—Time1.TwentiethtoDefinitiveCenturyMilitaryCare
Campaign
MilitaryDefinitiveTimetoCare
Mortality
WorldWarI(WWI)12–18hours8.5%WorldWarII(WWII)6–12hours5.8%KoreanConflict2–4hours2.4%VietnamWar
65minutes
1.7%
DevelopmentofTraumaSystemsintheUnitedStatesInthehistoryofmedicine,traumasystemsmustbecon-sideredarelativelyrecentdevelopmentandonewhichisinitsearlyevolution.Inthelate1950sandearly1960s,severalstudiesshowedsuboptimalclinicaloutcomesincivilianpatientswithtrauma.15,16,24,28Asignificantnum-beroftraumamortalitieswerethoughttohavebeenavoid-ablewhenamoresystematicapproachtoseverelyinjuredpatientswasused.Outofthesestudies,theconceptofpreventabledeath,usedroutinelyinmodernperformanceimprovementreviews,wasidentifiedasonewaytomea-sureoutcomesintraumasurgery.
In1966,theNationalAcademyofSciencespublishedAccidentalDeathandDisability:TheNeglectedDiseaseofModernSociety,1whichhighlightedtheinferiorstateoftraumacareinthiscountryatthetime.This“whitepaper”alsodescribedthesignificantsocietalandeconomicim-plicationsassociatedwithprovidingsubstandardcaretoinjuryvictims.1Severalrecommendationsincluded:evalu-ationoftransportationmodalitiesforlesspopulatedareas;provisionofeducationalopportunitiesforprehospitalper-sonnel;completionofaresourceassessmenttodeterminewhatresourceswereactuallyavailableforthemanage-mentofseverelyinjuredpatients;establishmentofregis-triestoaccumulatedataspecifictopatientswithtrauma;andprovisionoffinancialsupportforspecializedcen-ters.12PublicationofthispapermarkedthebeginningofmodernEmergencyMedicalServices(EMS).5
Illinoisestablishedthefirstformalregionaltraumasys-temin1971.TheIllinoisTraumaProgramconsistedofdesignatedfacilitiesfortraumaandburncare,withthreecategoriesdefined:LocalTraumaCenter,AreawideTraumaServiceCenter,andRegionalTraumaServiceCenter.5TheEmergencyMedicalServicesAct(P.L.93–154)of1973providedfunding,guidelines,andtechnicalsupportforthedevelopmentofregionalizedEMSnation-wide.10ByrecognizingtheimportanceofEMSandthespecialneedsofthepatientwithtrauma,thislegislationhadsignificantinfluenceonthedevelopmentoftraumaandEMSsystems.Inaddition,theEMSActprovidedgovernmentfundingfortrainingandequippingEMSper-sonnel.4,5,19
andClinicalRelatedOrthopaedicsResearch
In1976,theAmericanCollegeofSurgeonsCommitteeonTrauma(ACS-COT)publishedOptimalHospitalRe-sourcesforCareoftheInjuredPatient.Thisdocumentestablishedacategorizationschemefortraumacentersandguidelinesfortherespectivetraumacenter.2Unfortu-nately,thedesignoftheseoriginalguidelinesexcludedmanyhospitalsfromparticipationinregionaltraumasys-tems.WiththepublicationofTheModelTraumaCareSystemPlan(1992),theconceptoftheinclusivetraumasystemwasintroduced.23Asaresult,subsequentversionsoftheACS-COTguidelineshavereflectedmoreflexibilityforindividualinstitutionsinterestedinparticipating.19ThemostrecenttraumacentercategorizationschemeisshowninTable2.
In1988,Westetal27reviewedthestatusoftraumasystemdevelopmentintheUnitedStates.Atthattime,onlytwostateshadalltheessentialcomponentsofare-gionaltraumasystem.Twenty-ninestateshadnotinitiatedanyformalprocessoftraumacenterdesignation.Amorerecentstudydocumentsthat35statesandtheDistrictofColumbiahaveformallyestablishedtraumacenters.11Clearly,EMSandtraumasystemsareevolving.TheoryofTraumaSystems
Thefollowingvignetteshowstheessentialcomponentsofatraumasysteminitsmostbasicform:
Amotorvehiclecollideswithatreeinaruralcountyandthedriverisejectedfromthevehicle.Heisfoundbyanothermotoristwhoflagsdownatruckdriverwhocalls911.Anambulancearrivesandtransportsthepatienttotheclosesthospital.Onrapidinitialsurvey,theemergencyphysicianfindsthemantobecomatoseandhypotensive,
TABLE2.
ACS-COTTraumaCenterCategories
TraumaDesignation
CenterDescription
LevelI
Clinicalcareofallaspectsofinjury
Tertiarycarefacilitycentraltothetraumasystem
Leadershiprolewithinthetraumasystem Educationandresearch Traumasystemsplanning
LevelII
Totaldefinitivecare—lesscomprehensivethanLevelI
Maybemostprevalentfacilitywithintraumasystem
LevelIII
Rapidassessment,resuscitation,emergencysurgery,stabilization
Transferformoredefinitivecare
LevelIV
ATLS-levelclinicalcarewithtransfertohigherlevelofcare
Resuscitationandclinicalcareperprotocol/guidelines