20HoffandSchwab
sionspecifictothecomplexissueoftriageinanorganizedtraumasystemispresentedinSectionX.Reliablecom-municationsystemsandrapiddispatchofprehospitalpro-vidersarenecessarytominimizetimetoaccess.Trans-portationofvarioustypesshouldbeavailabletoaccom-modategeography,populationdensity,andvariableenvironmentalconditions.Inacompletetraumasystem,therolesofeachacutecarefacilityinagivenregionmustbedelineatedwithrespecttotraumacare.Traumacentersideallyshouldbedesignatedbasedonestablishedcriteriaandpopulationdensity.Specialtycenterstypicallyaredes-ignatedtocareforpatientswithburns,pediatricpatientswithtrauma,andpatientswithspinalcordinjuries.Be-causetheywillberesponsibleforthemajorityofinjuredpatients,theactualroleofallhospitalsintraumacaremustbeestablished.Itisvitalthatallhospitalsdevelopformal-izedrelationshipswithdesignatedtraumaandspecialtycenterstoensurethat,whennecessary,patientshavereadyaccesstohigherlevelsofcare.Integratedrehabilitationservicesspecifictotheneedsofthepatientwithtraumacompletestheclinicalcomponentsofthetraumasystem.Aneffectivetraumasystemrequiresastrongadminis-trativeinfrastructure,asshownintheouterringofFigure2.Atsomelevel,legislationisnecessarytoestablishthetraumasystemasanentity,assignoverallauthorityforthesystem,anddirectnecessaryfunding.Aleadagency(gov-ernmentalorprivate)mustbechargedwithoversightofthesystem.Suchoversightincludesdesignationoftraumacenters;regularevaluationoftraumacentersasdescribedpreviously(externalevaluationoraccreditation);andcon-tinuousqualityimprovement(internalevaluation)ofallcomponentsofthetraumasystem.Theleadagencyas-sumesresponsibilityforsystemdevelopment.Onacon-tinuousbasis,theneedsoftheregionandtheavailableresourcesshouldbeassessedtodeterminewhetherthesystemrequiresmodification.
Thefiscalaspectsofatraumasystemcannotbeig-nored.Unfortunately,thefinancialcommitmentassociatedwithtraumacenterdesignationandaccreditationisamajorimpedimenttoinvolvementformanyinstitutions.Further-more,economicissueshavebeenreportedasonefactorthathasforcedmanytraumacenterstogiveuptheirdes-ignation.Therefore,theestablishmentandsurvivalofor-ganizedsystemsoftraumacarearedependentonfinancialsupportasoneoftheessentialadministrativecomponents.EffectivenessofOrganizedSystemsofTraumaCareTojustifythetremendousresourcesrequiredtoestablishandmaintaintraumacentersandtraumasystems,itises-sentialthattheybeeffective.Numerousstudiesintheliteraturehavedocumentedthebenefitsoforganizedtraumasystemsonpatientoutcome.6,9,13,16,17,20,21,26Thissectionwillhighlightsomeoftheclinicalstudiesthatcom-
andClinicalRelatedOrthopaedicsResearch
paretraumacarebeforeandaftertheinceptionofvariousformsoforganizedtraumacare.
Earlyinthecourseoftraumasystemsdevelopment,severalstudiesclearlyshowedclinicalefficacy.In1979,Westetal26comparedpreventablenonneurologictraumadeathsbetweenpatientsinacountywithdesignatedtraumacenters(SanFrancisco)andpatientsinacountywithnodesignatedtraumacenter(OrangeCounty).InOr-angeCounty,37%ofthedeathsweredeemedpreventablecomparedwith6%inSanFrancisco.Cales6reportedareductioninpotentiallysalvageabledeathsfrom34%to15%http://www.77cn.com.cningconcurrentauditmethodology,Shackfordetal20documentedadecreaseintheincidenceofsubop-timaltraumacarefrom32%to4.2%afteraregionalizedtraumasystemwasdevelopedinSanDiego.
TwostudiesfromOregonhaveshownapositiveeffectontheprocessoftraumacarewiththeinceptionofaformaltraumasystem.AfterestablishingatraumasysteminthePortlandregion,Mullinsetal13showedthat77%ofseverelyinjuredpatientswereadmittedtoLevelItraumacentersand72%oflessseverelyinjuredpatientswereadmittedtonondesignatedhospitals.Therefore,thetriageandtransportprocessesweredocumentedtobefunctional.InasimilarstudybyHedgesetal,9thepercentageofpatientstransferredfromLevelIVtraumacentersandnon-designatedhospitalstohigherlevelsofcarebeforeadmis-sionwasreportedtoincrease.Thisfindingimpliesim-provementsinprehospitalevaluation,triage,andmedicalcommandassociatedwithamaturingtraumasystem.AdditionalsupportfortheefficacyoforganizedtraumacarehasbeenprovidedbyseveralstudiesfromCanada,wheretheeffectsoftraumasystemdevelopmenthavebeenreported.Stewartetal21reportedonoutcomesforpatientsinmotorvehiclecrashesbefore(1989–1990)andafter(1992–1993)designationoftraumacentersinOntario.Af-tertraumacenterdesignation,asignificantincreaseinac-tualsurvivorscomparedwithexpectedsurvivorswasshown.A5.2%reductioninunexpecteddeathswasre-ported.Similarstudies17,18fromMontrealhavedocu-mentedadecreaseinmortalityratefrom52%(preregion-alization)to18%(advancedregionalization),particularlyinthemoreseverelyinjuredpatientpopulation.MassCasualtiesandtheTraumaSystem
Themedicalliteraturehasnotspecificallyexaminedtheeffectofanorganizedtraumasysteminamasscasualtysituation.However,basedonthemodelinitiatedbytheAmericanCollegeofSurgeonsandrefinedintheModelTraumaCareSystemsPlan,itisreasonabletospeculatethebeneficialeffectsofatraumacaresystemforthetreat-mentofmasscasualties.2,23Majorpointsthatsupportthisnotioninclude:(1)Resourcesofallacutecarefacilities