Officials at UCLA Medical Center and Daniel Freeman Memorial Hospital fear that their ability to serve the Westside as part of the county's prestigious trauma center system will be impaired if more hospitals are added to the program.
Brotman Medical Center and Santa Monica Hospital Medical Center, which are fighting to be named trauma centers, will take their appeal to the Board of Supervisors on Jan. 15.
Brotman and Santa Monica claim their services are needed in the Westside and say their participation would enhance the county's program of round-the-clock medical care for the critically ill and injured at designated trauma centers.
Opponents say the additional designations would take patients away from existing trauma centers, thereby depriving doctors of the opportunity to treat trauma victims. They say that would jeopardize the quality of care and the training of trauma physicians.
The opposition includes the existing trauma centers at UCLA and Daniel Freeman, the county Department of Health Services and the American College of Surgeons, whose guidelines were used in establishing the county's trauma center program in December, 1983.
Some observers say the crux of the dispute is money, not quality of care. They point out that a trauma center designation can be an effective marketing tool, although some hospitals have lost money on their trauma centers. In addition, some hospitals fear that new trauma centers will drain off some of their paying clients.
Dr. Albert Yellin, chairman of the American College of Surgeons' Southern California committee on trauma care, said that it has recommended that trauma centers be able to attract enough patients to keep medical teams practiced in trauma care.
The American College of Surgeons recommended that trauma centers see a minimum of 300 trauma patients a year, with an even higher volume of 500 at so-called Level 1 trauma centers. Level 1 centers must offer physician training and research and must have heliports; Level 2 centers offer the same 24-hour medical care as Level-1 centers, but are not required to have heliports or residency programs.
In the Westside, UCLA Medical Center and Cedars-Sinai Medical Center are designated Level 1 trauma centers; Daniel Freeman in Inglewood, which serves Culver City and West Los Angeles, is a Level 2 center; Santa Monica and Brotman are seeking Level 2 designations.
UCLA and Daniel Freeman would be more affected than Cedars by the addition of Santa Monica and Brotman as trauma centers, said Virginia Hastings, chief of the county's Trauma Hospital Project. Both Brotman and Santa Monica hospitals are within UCLA's designated area, and Brotman is in Daniel Freeman's area, she said.
Hastings said that the health department originally estimated that Cedars would receive about 500 patients; UCLA, about 400, and Daniel Freeman "well above" the county's minimum guideline of about 350.
She said that the county has estimated that if Brotman and Santa Monica were added as trauma centers, the UCLA-area caseload would be divided as follows: Brotman, about 160; Santa Monica, about 120; UCLA, under 100.
Yellin said that if either Brotman or Santa Monica were to be designated as a trauma center, it would have "a major impact in drawing patients away from Daniel Freeman and UCLA."
At UCLA, he said, this would have a "catastrophic impact." Marshall Morgan, director of UCLA's Emergency Medicine Center, said that although Brotman and Santa Monica are excellent hospitals, "to designate them would essentially destroy the system as we've planned it. . . . We would have three centers (in UCLA's territory) and each would receive fewer than half as many patients as it should to function as a bona fide trauma center."
He said that UCLA receives about 350 trauma patients a year, but if Brotman and Santa Monica were added, UCLA's patient load would drop to less than 150.
At that rate, Morgan said, the center would not be able to offer residents enough practice in the care of trauma victims, thus jeopardizing the quality of care and UCLA's ability to provide training for trauma surgeons, he said.
Officials said that Daniel Freeman would also be affected by the additional designations, but the impact would be primarily financial.
Hastings said that according to the county's estimates, Daniel Freeman's caseload would remain above the minimum guideline of 350 even if Brotman were added.
But she said that Brotman would draw away Daniel Freeman's primary source of paying patients from Culver City and West Los Angeles, leaving Daniel Freeman with a predominantly non-paying clientele.
Steven Goe, vice president of administration at Daniel Freeman, said adding Brotman as a trauma center would "work a severe hardship (on Freeman), and put in doubt whether we can continue to serve as a trauma center for this community."
Susan Linderblood, a registered nurse who is coordinator of trauma services, said Daniel Freeman expects to receive about 700 patients a year at its trauma center, which opened in June.
Goe said that the current "patient mix" at the Inglewood hospital includes enough paying patients to offset patients who cannot pay for their care.
Daniel Freeman's trauma center is operating at a loss, Goe said, but officials hope that by the end of its first year it will break even financially.
In appraising the outlook for Daniel Freeman, sources cited the experience of California Hospital Medical Center, which last month announced that it will shut down its trauma center. Officials said the center is being closed because it became too costly to provide emergency medical care for the hospital's Los Angeles service area, which included a large percentage of non-paying patients.
When California Hospital closes its trauma center on Feb. 1, 20 hospitals will be left in the trauma center system throughout the county.
The original plan was to establish Level 1 trauma centers with geographic territories that would allow for the transport of victims within 20 minutes, Hastings said.
The 20-minute goal was established not because of medical research showing that time as being critical for patient survival, Hastings said, but because fire and paramedic agencies wanted to make sure that their rescue vehicles would be available instead of being tied up on long runs.
Hastings said that once the Level 1 centers were established, the county asked for applications for Level 2 trauma centers in areas farther than 20 minutes from the Level 1 centers.
"With Daniel Freeman and UCLA, we believe that practically all trauma patients in the Westside can get to a trauma center within 20 minutes," she said. One of Santa Monica Hospital's strongest arguments for being designated a trauma center is that it is nearest to Malibu and Pacific Coast Highway, parts of which are more than 20 minutes from UCLA.
UCLA sources argue that helicopter service brings victims to UCLA speedily and that Santa Monica is only 5 or 10 minutes closer by vehicle than UCLA, a difference they say is not often critical to the patient's survival.
Leon Vargas, assistant vice president at Santa Monica Hospital, said his hospital is the medical center closest to Malibu and Pacific Coast Highway. In many cases Santa Monica ends up receiving trauma victims because UCLA would exceed the county's 20-minute guideline, he said.
Asked whether the designation of Santa Monica would have a negative effect on UCLA, he said, "It may be true that we would take some patients from UCLA." If both Brotman and Santa Monica were designated, it "undoubtedly" would have an impact, he said.
Vargas suggests that Santa Monica receive an "interim" designation as a trauma center. During this interim period the county could study caseloads at various hospitals and determine the best locations for trauma centers, he said.
Vargas said that Santa Monica has estimated it would receive 125 to 150 trauma patients a year if it were named a trauma center. He said that before the designation of UCLA as a trauma center, Santa Monica received more trauma patients than any other hospital in the Westside.
Gary Maier, associate administrator, said Brotman also has challenged the county's statistics and is seeking an interim designation until more conclusive patient counts can be made.
"We think the numbers (of trauma patients) are significantly higher," Maier said. "We have been functioning as an unofficial trauma center for years. Our main concern is to serve the residents we have always served."
Maier said some patients (he said he could not cite an exact number) who previously would have been taken to Brotman now are being to county-designated trauma centers. In the past, he said, Brotman's clientele has included enough paying customers that providing trauma care has not proven to be a financial problem. Skeptics say that the fierce competition among hospitals for designation as trauma centers is strictly a business proposition.
"It is primarily a marketing tool," said one source. "The hospitals get a lot more publicity as trauma centers; they get to hang signs outside. This helps bring in patients other than trauma victims. People automatically assume if you are a trauma center, you offer the best medical care in everything."
Ironically, this added prestige did not enable California Hospital to break even on its trauma center. Hospital officials there estimated that in 1985 its trauma center operations would have lost $5.3 million.
But in the Westside, where the majority of residents have medical insurance and are capable of paying their hospital bills, the competition remains intense for trauma center designation. If the trauma center just breaks even, some administrators figure, it is worth it to have the program as a means of attracting patients to the hospital.
"That's why administrators go after the (trauma center) designation tooth and nail," one doctor said.