Six years ago, an expert panel made a strong suggestion to the White House: set up a national system to care for patients with traumatic injuries, which lead to about 30,000 deaths every year. “In the civilian sector, where injury is the leading cause of death for Americans under age 46, as many as 1 in 5 deaths from traumatic injuries may be preventable with optimal trauma care,” the authors wrote.
A national system has yet to emerge, but new research published in the Journal of the American Medical Association has found that access to trauma care improved in the 2010s. The study mapped the distance from each census block to the nearest trauma center, taking into account air and land transport. The researchers found that 91% of people in the U.S. could get to a trauma center within 60 minutes by air or land travel, up from 78% in 2013.
“We shouldn’t be applauding that,” said Brian Daley, chief of the trauma division at the University of Tennessee Medical Center, who was not involved in the new research. “We should say we’re still lacking 10%.”
Trauma centers differ from regular hospitals — they have to meet certain benchmarks on care and have specific staff on call around the clock. “That is the difference oftentimes between surviving a trauma and surviving it well and not having long-term effects from it, and not surviving or having permanent problems from it,” said Elizabeth Benjamin, trauma medical director at Grady Memorial Hospital.
The study, which looked at trauma centers verified by the American College of Surgeons, found that access differed across regions. Native Americans faced the lowest access to trauma care at 70%, as well as the smallest improvement to access among any group. The share of people living in proximity to a trauma center was also lower in rural states like Wyoming, Montana, and South Dakota, and in the South, where it dipped below 50% in two states. “Most in the South still have periods where it takes over an hour to get to a trauma center,” said Daley. “And you would think in the 21st century, even with helicopter access and incredible ground transport, that that would not be a problem. But it is.”
The study authors and other experts said the study underestimates access to trauma care, however, because certain states have their own programs for accrediting centers, particularly Washington and Pennsylvania.
There are several factors that have driven improvement in access, including an increasing emphasis on national verification in states like Tennessee and Georgia. Georgia has specifically also been encouraging trauma centers in areas that currently need one, according to Regina Medeiros, the trauma program director at the Medical College of Georgia. “Within our state, it was a conscious effort to be able to increase the numbers appropriately to ensure access to all the citizens,” said Medeiros, who is also part of the Georgia Trauma Care Network Commission.
Even when states already have their own programs for designating a trauma center, the field still sees national-level verification as an additional level of assurance.
“We witnessed trauma centers that were state-designated but not nationally verified,” said Oscar Guillamondegui, chief of the trauma division at Vanderbilt University Medical Center. “And as they move to verification, you can actually see their outcomes improve.” At Vanderbilt, which secured national trauma center certification for adult care in 2011, that means he now has a deeper bench of expertise he can call on in an emergency.
“That verification process isn’t just about the trauma surgeon. It’s about the orthopedist. It’s about the neurosurgeon. It’s about the emergency medicine team that’s helping out. It’s about the physical therapists that are going to help manage. It’s about the anesthesiologist,” said Guillamondegui, who was not associated with the study. “All of those aspects come into play and that’s what grows that improvement in outcomes.”
He also pointed to another, more intangible shift that has changed the face of the field — the general growth in awareness of trauma care as a specialty. After the Affordable Care Act passed, he said, there was an increased emphasis on the field. Hospitals started sending patients in need of that level of care out of local ERs and to dedicated trauma centers. The medical education system, too, started producing more and more specialists to treat those patients. “When the tide rises, all boats rise evenly. And I think that’s what you’re seeing as an effect of this process,” Guillamondegui said.
Some experts also said that there has been a growth in new trauma centers, particularly of for-profits. “For-profit hospitals realize that they can make a profit,” said Daley. “In many of those places that expanded Medicaid, the reimbursement improved, and so there were additional resources to put into things like trauma. So I think overall, the financial picture improved for people to take care of trauma patients.”
Jeff Choi, a surgery resident at Stanford and co-first author of the new study, said he and his colleagues became interested in the subject after reading an article last year that suggested a for-profit hospital system was opening new trauma centers to generate profit rather than improve patient care.
“There’s been this feeling that there’s been an expansion of trauma centers by certain for-profit health care chains where they’re sort of putting trauma centers where they think they can make money, maybe not necessarily where the need is,” said David Spain, trauma chief at Stanford and senior author of the study.
Spain also said that he worried lower-level trauma centers opened by for-profit operators would draw patients away from level 1 trauma centers that offer higher-quality care. In Florida, which saw access rise nearly 60% between 2013 and 2019, all of the level 1 centers verified during that time were governed by nonprofit systems, while all of the newly credentialed level 2 trauma centers were run by a for-profit company. “There was some data out of Florida that sort of implied that a lot of the new trauma centers were placed, maybe not in areas of high need, but areas where it was a good business venture,” Spain said. “You may decrease the amount of patients that actually come to the level one trauma center, they just all go to these level 2s out in the suburbs.”
Choi said the study authors are examining trauma center verifications and financial incentives more closely in a follow-up analysis. In the meantime, experts hope for more support from the federal government, including the national trauma network proposed in 2016.
“This work was done primarily by states and by organizations outside the federal government,” said Daley, who is chair of the Tennessee Committee on Trauma. “For many years, our trauma organizations have fought for a unified national system with help through the government. And there’s no fancy ribbon for trauma. There’s no National Trauma Month, or anything like that.”
To Guillamondegui, the progress seen so far in improving access to care — and the interest in continuing to improve access — mirrors the nature of trauma medicine.
“There’s never a time that we’re sitting on our laurels. There is never a time that we’re saying, ‘We’ve done enough. It’s time to stop,’” he said. “The fact is that medicine pushes the boundaries at all times to try and improve that care for patient populations.”
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