In five years, the new Alabama Trauma and Health System became a national model of emergency care — a statewide, high-tech MASH team that cut highway deaths by 29 percent. Trauma patient transfers that used to take six hours have been cut to six seconds.
Trauma team at work. Expert day and night coverage helps a hospital win Level 1 Trauma Center designation, like this at the University of South Alabama Hospital in Mobile.
Photo courtesy of USA Health System
Within the past few years, dozens of new hospital trauma centers have sprung up in Alabama. The numbers are part of a national trend, but Alabama is not typical of the trend.
More than 200 trauma centers have opened across the nation since 2009. The surge is because these centers have become increasingly profitable, erupting in controversy in some states, including Florida. Competing hospitals have argued the creation of unnecessary trauma centers only increases costs for hospitals, taxpayers and consumers.
Alabama is one of a handful of states with a particularly large increase in trauma centers, according to Kaiser Health News. But Alabama’s increase did not cause a battleground of competitors. Instead, Alabama’s expanding system of emergency care has fast become a model of efficiency in closing a critical gap.
Alabama’s new statewide trauma system, managed by the Alabama Department of Public Health (ADPH), is making better use of medical resources and promoting closer cooperation among hospitals and Emergency Medical Services (EMS). It’s also reducing trauma fatalities and improving quality of life for patients post-trauma.
“Before the state trauma system was up and running, about 60 percent of trauma patients in Alabama were first transported to hospitals without trauma capabilities,” says Dr. John Campbell, who retired as the ADPH medical director for EMS and trauma last year and currently serves as a spokesman for the Alabama Hospital Association on the state trauma system.
While only about 28 percent of motor vehicle crashes here in Alabama were in rural areas in 2006, those accidents accounted for more than two-thirds of the trauma deaths, according to the U.S. National Highway Traffic Safety Administration.
The trauma system was designed in part to lessen a significant state problem. “Alabama has one of the highest per capita highway trauma death rates in the country,” says Choona Lang, administrator of the ADPH trauma system.
Created by legislation in 2007, the Alabama Trauma and Health System (ATHS) is designed to coordinate regional trauma resources through the Birmingham-based Alabama Trauma Communications Center. The goal is to monitor emergency resources 24 hours a day, seven days a week, via a trauma hospital intranet system, so that EMS personnel can quickly transport trauma victims to the nearest trauma center with available resources to best provide for a trauma patient’s needs.
Survival rates significantly decrease when critically injured patients don’t receive proper treatment within an hour of their injury. Trauma victims have a 25 percent higher survival rate when they are treated at a trauma center, according to a 2006 New England Journal of Medicine study.
“Trauma has surpassed heart disease as the most expensive medical problem across the country. Total yearly economic cost in Alabama is $6.5 billion,” Campbell says. “When trauma patients don’t get to the right hospital the first time, costs increase.”
Since the state trauma system has been instituted, significantly more trauma victims in Alabama are transported to the correct hospital. That may be a major reason why the state’s highway fatality rate has improved in recent years. Whereas Alabama had the fourth highest per capita highway trauma death rate in the U.S. in 2006, by 2010 it had dropped to 11th highest. There was a 29 percent decrease in traffic fatalities in Alabama from 2006 to 2010 in spite of an increase in the number of patients injured.
The model for the state trauma system is the Birmingham Regional Emergency Medical Services System (BREMSS), which covers a seven-county region. The organization is part of the University of Alabama at Birmingham Health System and directed by a diverse board of government and health care representatives. The communications center, manned by paramedics, coordinates 9-1-1, emergency medical technicians, ambulances, helicopters and health care resources, including trauma centers.
Between 1996, the year BREMSS was initiated, and 2005, there was a 12 percent decrease in the death rate from trauma in the region, a decrease not seen in other areas of the state. For its success, BREMSS was honored with a Mitretek /Harvard Innovations Award for Homeland Security in 2006. The award caught the attention of then Gov. Bob Riley, who with others advocated for state trauma system legislation, says Joe Acker, BREMSS executive director. “We had been pushing for a statewide trauma system because we knew what a difference it could make, but it was the award that really got things going,” he says. “We still are challenged by limited funding for the program.”
Because BREMSS had the infrastructure and high-tech resources, including support software, its communication center expanded to become the state trauma communications system. Participating hospitals get a computer and software and use a dedicated data line to give the communications center real-time updates on the status of their trauma resources. EMS personnel don’t have to waste time taking a trauma victim to a hospital trauma center that can’t handle the patient for whatever reason. “At first they were concerned having to call in to the communication center would slow things down, but soon they learned how much smoother things went when they could quickly learn which trauma center was available,” Acker says.
Currently five of the six Alabama trauma system regions are connected to the central communications center. The sixth region, Southeast Alabama, which includes Montgomery and Dothan, hasn’t been able to get participation from enough trauma physicians, primarily orthopedic surgeons at larger hospitals. Numerous small hospitals in the regions have already been approved as lower level trauma centers. “We continue to work to convince a few key players how much the system could improve patient outcomes,” Campbell says. “The system is voluntary, so they could give it a try and later opt out if they weren’t happy with it.”
Campbell and Acker believe a pilot stroke communications system recently set up for Southeast Alabama will demonstrate the value of coordinated communication. The pilot program is designed to help EMS personnel get stroke victims to a hospital that is prepared to act quickly with the best test and treatment options, since fast action improves survival and recovery rates.
“The goal for the system is for all the regions to eventually have a coordinated system for response to stroke and cardiac emergencies as well as trauma, just as BREMSS has had with great success,” Acker says.
The state trauma system relies on a network of trauma centers, each designated Level 1, 2 or 3 by the state. State standards are similar to those used by the American College of Surgeons, which verifies the quality of trauma centers. Level 1 trauma centers are required to have their operating room adequately staffed with specialists and immediately available for trauma 24/7. Level 2 and 3 must be able to gather staff and operating room resources within 30 minutes.
The system currently includes seven Level 1 trauma centers — including UAB, Children’s, University of South Alabama and Huntsville Hospital and three in Florida and Tennessee, and two Level 2 centers in Decatur and Anniston. The vast majority of trauma centers, 45 across the state, are Level 3. Trauma patients may be routed to Level 3 trauma centers when their injuries don’t require a higher level of trauma care. In other cases, patients may benefit from being stabilized at a Level 3 center before being transferred to a higher-level trauma facility that might not be immediately available. Transfers between hospitals can be more quickly arranged through the trauma communications center. “It normally could take up to about six hours to get a trauma patient transferred. Now we can do it in as little as six seconds,” Acker says.
No certificate of need is required for an existing hospital to become a designated trauma center.
System representatives aren’t worried about having an excess of Level 3 trauma centers and would like to see more Level 3 centers come online in the West Region, which includes Tuscaloosa. “Because of the drive times sometimes involved in the West Region, depending on the location, EMS personnel may feel it’s in the patient’s interest to take the patient to a hospital not in the system,” says Michael Minor, BREMSS assistant director, who answers calls in the trauma communications center.
Other states, including Georgia and Louisiana, have studied Alabama’s trauma system and are trying to institute their own versions. “We have gotten attention from across the country, but, unfortunately, most states aren’t really set up to easily adopt a centralized system. One of the main reasons we were able to create a statewide system is because the state of Alabama was already regulating EMS personnel,” Campbell says. “They receive training and updates from the state on an ongoing basis.”
The Alabama Hospital Association has launched a new PR campaign touting the Alabama trauma system’s successes to increase public awareness and encourage greater participation by health care providers.
“People just assume that if they suffer a traumatic accident that they will be quickly transported to the right hospital, but that’s not necessarily the case. It greatly depends on where you’re located and what resources are available,” Campbell says.
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Kathy Hagood is a freelance writer for Business Alabama. She lives in Homewood.