Survey of U.S. Regional Trauma Organizations

The authors offer guidance to encourage strong regional trauma organizations globally.

Abstract

Background: There appears to be great variability in Regional Trauma Organization (RTO) function. The purpose of this study was to assess what functions RTOs perform across the United States and attempt to identify common practices to begin determining best practices.

Methods: Membership of a national trauma center association were surveyed anonymously.

Results: Eight hundred ninety-eight members representing 387 hospitals were surveyed with 100 responders representing 26% of the hospitals . Seventy-four% of the responders were trauma program managers. Eight-one% of the responders had an RTO in their region and 98% participated in their local RTO. The majority of those RTOs were governmental (62%) and voluntary (56%). Eighty-four% of RTO’s included all Trauma Centers in the region. These RTOs included non-trauma center acute care hospitals and other entities 56% of the time and 96% included other trauma providers (emergency medical services, etc.).

Sixty-nine% of RTOs focused on trauma. For those whose scope extended beyond trauma, most included other time critical diagnoses (TCD). The majority developed regional protocols, provided community support, quality improvement and support for disaster planning. A minority of RTOs managed regional trauma registries, regional trauma quality improvement programs, trauma center support for verification and diversion and disaster coordination. RTO trauma education included Advanced Trauma Life Support (ATLS®) courses (20%), nursing education (58%), Disaster Management and Emergency Preparedness courses (DMEP™) (45%) and other trauma related education (76%).

Conclusion: The responses suggest that there are real opportunities in developing standard criteria as a best practice for the RTO in several areas. 

Introduction

The development of trauma centers and systems sprung from the recognition that outcomes for trauma victims were highly variable and ranged, with a few notable exceptions in our very largest urban areas, from adequate to bad. Emergency medical services (EMS) did not exist as we know them today. It was common for the local funeral director and his hearse to moonlight as EMS and the hearse would become an “ambulance.” No prehospital care of note was available. The National Research Council report, Accidental Death and Disability – A Neglected Disease of Modern Society, spurred a number of legislative actions which led to modern EMS systems.1-3 The American College of Surgeons Committee on Trauma (ACSCOT) developed Optimal Care Guidelines for the Management of Trauma Patients in 1976 and have periodically updated them since.4

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In the U.S., regional trauma systems have been shown to decrease the mortality and morbidity associated with injury.2 A similar experience has been reported internationally. Trauma systems save lives by assuring the right patients get to the right facility at the right time. Implementation of regional trauma systems have shown to decrease mortality from 15 to 20% pre and post implementation. Trauma systems coordinate injury management across a functional or geographic region. In 2011, it was estimated that 90% of states had some form of regionalized trauma care.5 Most of the early trauma systems were collaborations between local trauma centers and did not include non-trauma centers. They were “exclusive,” by definition.

Inclusive trauma systems incorporate medical facilities defined by a geographic area into a hierarchy that encompasses multiple facilities of differing capabilities whether they are or are not trauma centers.6 The Regional Trauma Organization (RTO) is a relatively new development which puts the coordination of regional care in an organization based upon regions, which often includes resources beyond those of a single hospital or trauma center. There is a paucity of information on RTO in the literature. This study uses an anonymous survey methodology to identify a baseline for the scale and scope of the United States RTO.

Methods

Membership of the Trauma Center Association of America representing members in 44 states were surveyed anonymously with an online tool. The survey link was active for two weeks and the members received one reminder to participate. Each facility was asked to have only one person fill out the survey. No potentially identifying questions related to institution or individual were asked, but the position of the responder was recorded. The survey included the structure of the RTO (type of organization housing the RTO), scale of the RTO (who is involved), and the scope of the RTO (what does it do). The survey questions asked are represented in Table 1.

Results

Eight hundred ninety-eight members representing 387 hospitals were surveyed with 100 responders representing 26% of hospitals. Seventy-four% of the responders were trauma program managers, 21% were trauma program medical directors and 5% were administrators. Eighty-one of 100 responders had an RTO in their region and were utilized for further analysis. Since the survey was anonymous, we do not know exactly how many of the trauma centers were associated with an RTO. Seventy-nine of those 81 (98%) participated in their RTO. The plurality of those RTOs were government-based (48%), 11% were hospital-based, 14% were free-standing and 4% of the responders did not know. Forty-five of 81 (56%) responded that their participation was voluntary. The RTO included all trauma centers in the region 84% of the time. These RTOs included non-trauma center acute care hospitals, and other administrators 44/79 (56%) of the time and included other trauma providers (EMS, etc.) 96% of the time.

The majority of RTOs focused exclusively on trauma 44/79 (69%). The 31% that included other acute care diagnoses beyond trauma contained functions related to acute cardiac events (91%), stroke (96%), sepsis (32%), and others (22%) such as Maternal and Neonatal, Emergency Medical Care, Emergency Preparedness, Burn, and Drug Overdose. The majority developed regional protocols, provided community support, quality improvement, and support for disaster planning. The minority of RTOs managed regional trauma registries, Regional TQIP®, trauma center support for verification, or diversion and disaster coordination.

RTO trauma education included ATLS® (20%, n =80), nursing education (58%, n =81), disaster management and emergency preparedness courses (DMEP™) (45%, n =81) and other trauma related education (76%, n = 81).

Discussion

The ideal trauma system was described by The Health Resources and Services Administration in 2006.7 Pigneri and co-workers provide a concise summary of trauma system development.8 It is not surprising that the majority of RTOs focus on trauma. What was surprising to the authors is that the minority of RTOs managed regional trauma registries, regional trauma quality improvement programs (TQIP®), trauma center support for verification, and diversion and disaster coordination. The authors believe these functions are integral to a well-functioning trauma system whether hospital-based or free-standing.  Additionally, the lack of consolidated education programs may be less efficient than RTO-based education and could exhaust individual hospital resources. It is not clear if these omissions are due to available funding, resources, or the local politics of competition.

It is also not surprising that the minority of RTOs provide coordination or other action on emergency services and time critical diagnosis. These efforts can be costly and labor intensive and politically charged. Expanding membership beyond local trauma centers and the development of mutual trust may help with these issues. Bringing emergency service partners (hospital emergency medicine and EMS), emergency preparedness, and public health to the table also forces a broader discussion on issues of community importance, such as destination and diversion protocols, standard definitions of facilities and resources, standard protocols, and quality assurance beyond trauma, especially during an extended real-world pandemic in which we are living at the time this article was published.

The RTOs in Ohio

In 1982, State of Ohio trauma leaders through the Ohio State Medical Association (OSMA) began to explore an organized system of trauma care for Ohio. Unfortunately, multiple attempts through the OSMA and the Ohio Legislature failed to pass laws to regionalize trauma care.9 We will describe the development of Central Ohio’s RTO (COTS) as an example of what we believe a high functioning RTO might look like.

Central Ohio Trauma System (COTS)

By 1995, in the absence of a State-wide solution, the clinical leadership from Franklin County hospitals came together to discuss opportunities for regionalization. By 1998, COTS was formally chartered (501(c)3) as a regional consortium of physicians, nurses, first responders, data specialists, researchers, acute care hospitals, trauma centers, city and county public health and other experts. The initial mission of COTS was to  reduce injuries and save lives by improving and coordinating trauma and emergency care and education in Central Ohio. The purpose of COTS was to serve as the forum for addressing the issues affecting the delivery of trauma and emergency healthcare services and injury prevention in Central Ohio.

Since its founding, COTS has become neutral territory for collaboration and standardization of care. While there were two adult Level I, one pediatric Level I, and two adult Level II trauma centers (and now an adult Level III trauma center, too) in Columbus, all agreed to check their institutional credentials and competitiveness at the door and work solely for the good of the entire community. This was a very important principle that allowed COTS to develop and assume a roll in central Ohio that none of the individual medical centers could. Today, COTS is housed at the Columbus Medical Association and is composed of three divisions: Trauma, Emergency Preparedness and Response, and Emergency Services for Time Critical Diagnosis. Standardized protocols, destination protocols, real-time bed census data, emergency preparedness (response and recovery coordination and situational awareness), centralized education and research involve all three divisions. Figure 1 represents COTS’ organization chart.

Figure 1

Over the last 25 years, COTS has expanded its geographic coverage solely on the basis of other institutions and groups requesting to join so that it now covers all of central, southeast, and southeast central Ohio which encompasses 37 of Ohio’s 88 counties and 17,844.26 square miles. It currently is composed of two adult Level I Trauma Centers, one Pediatric Level I Trauma Center, 2 adult Level II Trauma Centers, and three adult Level III Trauma Centers. In addition to the trauma centers, there are two burn centers (one adult and one pediatric), 48 acute care hospitals, free-standing emergency departments (EDs), and alternate care sites submitting data to COTS’ regional trauma registry. COTS’ RTO partners also include 39 public and private EMS agencies including two helicopter air ambulance transport companies, and the City of Columbus and Franklin County government and Public Health departments. At the time of this publication, COTS is in the process of expanding its membership to public and private first responders. The State of Ohio requires all trauma centers to be verified by the American College of Surgeons. Funding for COTS is provided by member dues, special project grants, ongoing emergency preparedness grants from The Assistant Secretary of Preparedness and Response (ASPR) and the Ohio Department of Health (ODH), and generous annual financial support from The Columbus Medical Association and its Foundation.

COTS acts as a central clearing house for the region’s trauma data collection and submits trauma data for its member facilities to the State of Ohio Trauma Registry. In addition, through a number of committees, COTS engages in regional quality improvement, including a Regional Trauma Quality Improvement Program (TQIP®), and centralized trauma education Advanced Trauma Life Support (ATLS®), Trauma Nursing Core Course (TNCC™), Disaster Management and Emergency Preparedness (DMEP™) Course, Emergency Nursing Pediatric Course (ENPC™), Trauma in the First 48 Hours Course©, and a number of other nursing, trauma quality, EMS, and registrar courses).

COTS acts as the Regional Healthcare Coordinator and convener for emergency preparedness and response for Central, Southeast, and Southeast Central Ohio (see COTS Region Map Figure 2) and manages the distribution of federal grants from ASPR and ODH. COTS recently conducted one of the largest mass casualty drills in the recorded literature with 445 mock victims from three sites, 11 hospitals and 25 agencies.10

Figure 2

The Emergency Services division fosters best practice and destination protocols for non-injury Time Critical diagnoses. It is best known for its ability to ensure the right patient gets to the right hospital through a collaborative diversion process and an Emergency Patient Transport Plan.11 Most recently it developed standardized handoff guidelines for first responders and Emergency Departments (ED)12 and began offering group purchasing for first responders.

An example of COTS’ high level of function was its ability to serve as the lead agency in standing up a regional surge hospital for the COVID-19 pandemic at the Greater Columbus Convention Center. The state, county, and city health departments, hospital representatives (CEO, CMO, and emergency preparedness directors), Franklin County Emergency Management and Homeland Security Director, and president of the Central Ohio Hospital Council were hosted by COTS for a planning meeting on March 23, 2020. A leadership team was organized, and with the help of the Ohio National Guard and Army Corps of Engineers a plan was created within two weeks of that first planning meeting. Within 72 hours of a decision to open the facility, 1,195 patient beds could be opened. All policies and procedures had been created and staffing identified; and it was done very efficiently. While the beds have not yet been activated, the total cost to stand up and stand down the facility was just under $2.4M or $1,991/bed. This is approximately one-third the cost of the same process in New York City and 21% of the cost to do so in Detroit.13 The key issue is not the cost but the fact that COTS was so respected in Central Ohio that it was asked to lead this process and was then able to bring the skill and talent together to accomplish the goal. It is a good example that as long as the goal is to help the patient, or, in this case the community, and avoid the common competitive pressures to fight at an institutional level about “who is best,” great things can be done for the community.

There are five other RTOs in Ohio, and we will attempt to describe each RTO using information from their websites and/or most current trauma reports to highlight the variability in RTOs that we suspect is likely the case on a national basis.

The Northern Ohio Trauma System (NOTS) was established in 2010 in Cleveland as a collaboration of Northeast Ohio hospital systems with the mission of improving the care of patients with traumatic injuries in Northern Ohio. It is composed of two adult Level I Trauma Centers, one adult Level I trauma center and combination pediatric Level II trauma center, one pediatric Level I trauma center, two adult Level II trauma centers, four adult Level III trauma centers and 24 non-trauma centers. The organization functions to collect regional registry data from only trauma centers. Member hospitals submit their own trauma data to the State of Ohio. They develop protocols through the Quality Committee, Research Committee and the Regional TQIP® Collaboration. They also support injury prevention efforts through their Regional Violence Interrupter Program and a Stop the Bleed Regional Initiative.14 NOTS focuses primarily on trauma and is supported by its system members.

The Southwest Ohio Regional Trauma System (SORTS) was established in 1999 as a program of the Greater Dayton Area Hospital Association (GDAHA). The SORTS Committee manages a regional trauma registry that collects, tracks, and analyzes prehospital and hospital trauma data and reviews select cases for performance improvement purposes. It is composed of one adult Level I trauma center, one adult Level II trauma center, two adult Level III trauma centers, one pediatric Level I trauma center, and 20 non-trauma centers. SORTS’ primary focus is enhancing trauma care and is supported by GADHA membership. SORTS submits its member trauma data to the State of Ohio. In addition to SORTS, GADHA offers its members several other services including but not limited to advocacy, quality review, health information exchange program and group purchasing, as well as committees or task forces for the following: EMS coordinators, ethics consortium, healthcare reform, infection control, mental and behavioral health, nurse executives, public affairs, social workers and regional healthcare preparedness. GADHA also manages the state of Ohio’s mass casualty patient tracking and reunification website called Surgenet.15

The Tristate Trauma Coalition (TSTC) began its collaborative meetings in 1999 and became a subsidiary of the Greater Cincinnati Health Council in 2004; now known as The Health Collaborative of Greater Cincinnati, Northern Kentucky, and Southeast Indiana. The fact that TSTC covers parts of three states makes it unique in Ohio but also demonstrates that organizing and leading health care can be accomplished across state borders. TSTC began management of a regional trauma registry in 2007 and works collaboratively with its local trauma centers, emergency rooms, and EMS to analyze trauma data to drive performance improvement and injury prevention initiatives. It is composed of one adult Level I trauma center, three adult Level III trauma centers, one pediatric Level I trauma center and 20 non-trauma centers. TSTC submits its member trauma data to the State of Ohio and also offers the following centralized trauma and emergency education: ATLS®, TNCC™, ENPC™, and Trauma Care After Resuscitation (TCAR®). TSTC’s primary focus is to ensure adequate trauma care for its region, and it is supported by membership in The Health Collaborative. Beyond the TSTC, The Health Collaborative offers its members additional services including but not limited to group purchasing, time critical diagnoses quality initiatives, disaster preparedness coordination, and coordination of a healthcare apprentice program.16

The Northwest Ohio Regional Trauma Registry (NORTR) was established in 1999 by the Hospital Council of Northwest Ohio in Toledo. It is composed of two adult Level I trauma centers with combination pediatric Level II trauma centers, five adult Level III trauma centers and 17 non-trauma centers. NORTR manages a regional trauma data registry and submits its member trauma data to the state of Ohio. It uses data analysis and evaluation to enhance trauma care for the citizens of Northwest Ohio, including but not limited to providing injury prevention strategies and peer review. NORTR’s primary focus is trauma, and it is supported by the Hospital Council. In addition to NORTR, the Hospital Council also supports the Northwest Ohio Disaster Preparedness Program and Northwest Ohio Pathways Hub, a program that connects citizens with social and medical services.17

The Northeastern Ohio Regional Trauma Network (NORTN), a program of the Akron Regional Hospital Association, was established in 2004. It manages a regional trauma registry that collects and analyzes prehospital and hospital data for the purposes of peer review, education, research, injury prevention and performance improvement. It is composed of two adult Level I trauma centers, two adult Level II trauma centers, one pediatric Level II trauma center and nine non-trauma centers. NORTN focuses primarily on trauma, submits its member trauma data to the State of Ohio, and it is funded by its Hospital Members. The Akron Regional Hospital Association offers the following services in addition to NORTN: emergency preparedness coordination for the Northeast Central Ohio and collaborates with members on quality, safety, transparency and accountability initiatives.18

The study has a few limitations. First, although the geography of survey distribution is known (44 states absent Montana, Maine, Nevada, Kentucky, Iowa, and West Virginia), because of the anonymity of the survey the geography of responders is not. It is possible more than one person per hospital filled out the survey and likely more than one hospital per region filled out the survey, making it difficult to tie potential best practice to RTO location.

Although the survey asked for the RTO parent it did not investigate funding which is often important in the RTO’s function, maintenance and sustainability. Those surveyed were Trauma, Center Association of America members, and a broader distribution could provide additional information. Finally, besides providing baseline information on the scope of function of RTOs in the United States and suggesting potential best practices, a definitive provision of best practice is not possible based on this survey. However, understanding the roles and scope various RTOs around the country have allowed us to begin to consider what the ideal components of an RTO might be. These limitations could be resolved with a more robust and detailed national survey to include geographic identifiers.

Conclusions

The responses suggest that there may be opportunities in developing standard criteria as a best practice for the RTO in registry, quality improvement, education, and scope beyond trauma to other time critical diagnosis, and emergency preparedness and response. We suspect that, depending on local or regional circumstances, that what constitutes optimal functions of the RTO may vary. For instance, in central Ohio, expanding the RTOs focus beyond trauma to other critical diagnoses served our community well. It would be easy to understand that in other communities there may already be other organizations that already manage stroke or STEMI. However, it seems intuitive to the authors that, if a community is considering developing an RTO or expanding an existing RTO, having a menu of options and, possibly, a baseline of needed minimum functions would be helpful.  

Acknowledgements

The authors would like to thank Jen Ward and Debra Myers of the Trauma Center Association of America for distributing the survey and collecting the data, and Wendi Lowell and Roxanna Giambri for their technical assistance.

Authorship Statement

Dr. Steinberg, Ms. Kovach, and Dr. Falcone all participated in development of the concept for this manuscript, creation of the survey questions, analyzing the results and writing the manuscript.

References

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11. Curcio, J E., and N Ferretti. “Ohio diversion plan keeps emergency patients moving.” EMS World, Nov. 2021, www.hmpgloballearningnetwork.com/site/emsworld/original-contribution/ohio-diversion-plan-keeps-emergency-patients-moving.

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