Four years into the system that is the gold standard for traumatic injury care around the country, doctors and administrators in San Diego County are beginning to wonder whether the next step is to refine the trauma network downward.
This idea--which would have been resoundingly rejected four years ago--brings San Diego once again to the forefront of innovative thought in trauma systems, this time regarding the financial problems that have plagued such systems from Los Angeles to Miami.
"I think we have evolved to the point that it may be time for some changes," said Dr. Steven R. Shackford, trauma director at UCSD Medical Center. "We in San Diego (are) sort of in the vanguard of what's happening. We've done it now for almost five years. We've met all the problems with, I think, innovative ways of coverage. And perhaps it's another step in the evolution of the model system here."
Suggestions Vary Widely
The suggestions for revising the system are so preliminary that they vary widely. They include ideas to:
* Downgrade some or all of the five Level 2 trauma centers to Level 3, which would turn them into well-equipped hospital emergency rooms. They would handle the majority of trauma victims, but have the ability and commitment to recognize major injuries that should be transferred to a higher-level trauma center, which likely would be at UCSD. This also could allow addition of more hospitals to the network, at Level 3 status.
The county network has one Level 1 trauma center, at UCSD, and five Level 2 centers, at Sharp, Scripps-La Jolla, Children's, Palomar and Mercy hospitals. The major difference between the levels is UCSD's mission to train trauma doctors and conduct research on traumatic injury care.
* Move toward a "Level 2 1/2" category, in which hospitals could have a formal commitment to trauma care without the stringent staffing requirements that have proved difficult to meet at the Level 2 hospitals.
* Reconfigure the system so that designated trauma centers resemble medical "boutiques" rather than "supermarkets." This would resolve the shortage of specialty doctors at the trauma centers by routing, for instance, all neurosurgical cases to a single hospital.
These ideas share the common thread of trying to dilute the economic and resource commitment required of trauma centers without sacrificing patient care.
But they present officials with a delicate balancing act between those two goals. Indeed, there is some concern those goals could not be reached without returning to the days when, doctors say, people were bleeding to death needlessly in hospital emergency rooms.
"I feel like (the system) should be scaled down. I think it's a difficult thing to do," said Dr. David Cloyd, chairman of trauma at Palomar Medical Center in Escondido, the center that has had the most difficulty meeting trauma staffing commitments.
"If we start reducing our sensitivity to the level of injury, and send the patients that appear to be less seriously injured to other hospitals, we're going to make mistakes," Cloyd said. "You'd have to accept the fact that occasionally you're going to make a mistake evaluating them in the field."
Such issues would have to be resolved before a trauma system revision could be accepted, and changes won't necessarily be adopted at all, said Gail F. Cooper, emergency medical services chief for the county.
"Those of us who are intimately involved in the trauma system are discussing all kinds of different ways that trauma care here and other places can be made better. Whether or not that leads us to reconfigure the system, I wouldn't go that far," Cooper said.
"We're at the ground floor of this discussion. The elevator door hasn't even closed yet," she said.
Currently, San Diego has six trauma hospitals to which the victims of shootings, stabbings, traffic accidents and other traumatic events are routed even if the injuries occurred closer to another hospital. The system treated 5,466 people in the 1986-87 fiscal year, and kept potentially preventable deaths to about two dozen cases, the county reports.
Millions in Losses
But it also has resulted in a concentration of no-pay or low-pay indigent cases that have brought losses to as high as $2 million a year to individual hospitals.
In other cities, such as Los Angeles, the underpayment problems have threatened to topple the trauma system as hospitals bailed out of it and emergency rooms faced closure.
San Diego's problems haven't reached that point, but the crisis may be approaching, officials say. Trauma surgeons and specialists such as orthopedists and neurosurgeons are being paid as much as $800 per 24-hour shift in exchange for being on call for trauma hospitals.
The situation is most critical at Palomar, where more than $700,000 of the $1.1-million trauma loss in the 1987-88 fiscal year was due to paying physician fees, said Tony Noronha, senior vice president for finance and business development.
Furthermore, emergency rooms all over the county are finding specialists increasingly unwilling to be on call to provide emergency-room care for which they probably will not be paid.
Such problems in San Diego, the state and nationwide provide the fuel for discussions of how trauma systems might need to change over the next five years.
"Whether in 1990 we will have the same system here in San Diego that we had in 1984, frankly I'll be surprised," said UCSD's Shackford.
The idea of having only one major trauma center, at UCSD, with other centers handling all victims of minor trauma is made possible by the county's sophisticated communications system for evaluating victims of accidents and violence, Shackford said.
"In 1984, the whole idea of a Level 3 hospital made us very nervous because we didn't have centralized communications. We didn't know what was out there bleeding to death in some emergency room," he said. "But now, if every case is triaged to the center by centralized communications, you have an idea what is out there and you can keep tabs on that patient. If there's deterioration, those patients can be transported."
In addition, it has become clear that non-trauma hospitals are an essential part of a trauma system.
"They must recognize minor injury and keep minor injury at their hospital, but also be able to recognize major injury and get that to a hospital with capabilities," Shackford said.
"If a little old lady steps off a curb somewhere and twists her ankle, gets a swollen ankle, and they go, 'Whoop, that's trauma. Send it to the trauma center,' that's the worst-case scenario. Because then your resources are consumed working up that little old lady."
The county's 1986-87 trauma system report hinted that non-trauma hospitals might be sending patients unnecessarily to trauma centers. It also noted that about 2,400 patients seen by trauma centers--nearly half the total trauma patient load--later proved not to have had major traumatic injuries.
"That's one of the directions we're going to be going in the next year, looking more carefully at who gets triaged," Cooper said. "We now have a good data base with which to study that, and that probably will be the system change we'll be looking at . . . more so than looking at a total reconfiguration of the system."
But she noted that there may be no way to cut down on these "over triage" patients, because emergency response time in the county is so fast. Ambulances often arrive on the scene "prior to the time that the patient's body has a chance to react to the trauma," Cooper said.
Delayed symptoms of internal bleeding or other problems are what signal the need for a special trauma team, but the transport decision frequently must be based on the mechanism of injury rather than the patient's apparent condition, Cooper said.
If accurate triage could be assured, there is no reason in principle that a downsized trauma system couldn't work, said Dr. Kimball Maull, surgery chairman at the University of Tennessee in Knoxville. Maull helped develop the American College of Surgeons' current guidelines for trauma centers.
"If you can identify all of the critically injured patients that need Level 1 trauma care, and get those patients to the trauma center . . . then (the others) can probably be taken to any full-service general hospital in the community and do well," Maull said.
Perhaps one of the stickiest issues in considering any revision of the trauma system will be in assuring such change would not increase the trauma burden for individual hospitals.
"I don't see any hospital in San Diego that's willing to devote itself to being a trauma center to any more capacity than it already is, including University Hospital," Palomar's Cloyd said.
Indeed, UCSD Medical Center administrator Michael R. Stringer balks at the notion of his hospital becoming the only one offering top-level trauma care.
"I think it would be fundamentally a mistake to change the system as is," Stringer said. "I think the six-hospital system performs very well, and seems to me to be just about the right number and the right geographical spread to manage our annual trauma volume.
"To increase any component of our programs by, for example, increasing our trauma load would unbalance the hospital."