‘Precarious Balance’ : Debate on Trauma Networks Continues

When the Los Angeles County trauma system was set up in 1983, private hospitals battled hard and even sued to be included in the prestigious network, regarded as the crown jewel of the county’s emergency services program.

This month, the 10th trauma center of the original 23 permanently bowed out of the system. On busy nights, half a dozen of the remaining ones are full and temporarily closed.

Problems are less severe in neighboring Orange County, where four of the five hospitals that started in the system in 1980 are still members, although they too are increasingly finding themselves overloaded with patients and sometimes sending trauma patients to other hospitals.

Overall, however, Orange County’s trauma system seems to be working, said Dr. John G. West, a surgeon at St. Joseph Hospital in Orange who is the author of national and local studies on trauma care. Still, he said, the network here maintains a “very precarious” balance.

“What we don’t realize is that our hospitals are barely making it” financially, West said. If one hospital’s trauma center closes--as Fountain Valley Regional Hospital and Medical Center warned it might last year--other trauma centers may be motivated to close too, West said.

Dr. Gregg Pane, an emergency physician at UCI Medical Center in Orange who is is chairman of the county Emergency Medical Care Committee, agreed that the pressure on trauma centers is intense.

The census in the medical center’s trauma unit has been at an “all-time high this month because other centers are overloaded and full,” he said. “There have been a number of cases where patients don’t (go) to the nearest trauma center.”

Asked whether that affects the outcome for patients’ injuries or illnesses, Pane replied: “I would think it probably does. We’re talking minutes . . . . If present trends continue, we’re at risk for potential closures. That affects all citizens, rich or poor alike, who may be in an auto accident, just as it does in (Los Angeles).”

Further Closures Feared

In Los Angeles County, several more hospitals may yet bail out. The number of temporary closures because of patient overload is way up over last year--”more than 1,000%” at Cedars-Sinai Medical Center in Los Angeles, for example, according to statistics from the Los Angeles Fire Department.

Some critics say that now is the time to evaluate the efficiency and effectiveness of the Los Angeles County trauma network, before allocating more money to revive it.

But the chairman of the Los Angeles County Emergency Medical Services Commission, Dr. Stephen L. Michel, warned that any tinkering “is fraught with danger and may gut the whole system.” He believes that the system’s only salvation lies in increased public funding. The commission is expected to present its recommendations today to the County Board of Supervisors.

In the meantime, growing numbers of Los Angeles County trauma patients are not getting to a trauma center at all or making it only in the nick of time.

Children ‘Barely’ Made It

For example, when a drunk driver ran down two children in South-Central Los Angeles last month, the trauma center less than 10 minutes away was closed to new patients. After waiting 15 minutes for an ambulance, the children--one with tire marks across his chest and a blood pressure that was falling--had to wait further for a helicopter to be summoned to fly them to the trauma center at Childrens Hospital in Hollywood, Los Angeles city paramedic Becky Hegwar said.

“They probably made it within the hour, but barely,” Hegwar said.

Unlike an emergency room, a trauma center is required to have a surgeon and anesthesiologist on the premises ready to operate and also a battery of other specialists such as orthopedists and neurosurgeons available within 20 minutes.

This staffing requirement is designed to ensure that patients bleeding from injuries to vital organs such as the brain, lungs and heart can be operated on quickly.

Overall, about 60% of Los Angeles County’s serious trauma injuries are caused by traffic accidents, health officials say. The rest are from violent crimes such as stabbings or shootings or from work-related injuries. The trauma system in Los Angeles County was originally designed so that no point in the county would be more than 20 minutes from one of 23 trauma centers.

In Orange County, trauma patients will get to one of the four existing centers--UCI Medical Center, Mission Hospital Regional Medical Center in Mission Viejo, Fountain Valley Regional Hospital, and United Western Medical Center-Santa Ana--within 20 minutes, said Betty O’Rourke, program director of the county’s Emergency Medical Services.

No North County Center

Pane acknowledged, however, that a trauma center currently is “missing” in northern Orange County. That area has been not been served since 1983, when two hospitals there decided to close their trauma centers because they were losing money.

At first, though, hospital officials were leaping at what they saw as a prime opportunity. As it turned out, though, most trauma centers lost money, and at a time when hospitals already were being squeezed by government and insurance cost controls. Worse, many surgeons and other specialists who staffed the trauma centers revolted when they discovered that many patients could not pay their bills.

Need Neurosurgeon

Fountain Valley Regional Hospital has recently been struggling with that situation. The hospital had been trying for six months to recruit a neurosurgeon and regularly closing temporarily to neurological trauma patients because it had no specialist to treat them.

In June, for instance, the hospital was closed to neurological trauma cases for 497 hours, said Barbara Patton, the hospital’s assistant administrator.

Finally, in July, the hospital persuaded a neurosurgeon from the Midwest to relocate. But he quit after six weeks, complaining of “no reimbursement or poor reimbursement,” Patton said. The hospital is now “back to square one,” often being closed to neurological trauma cases and still seeking a neurosurgeon, she said.

Overall, Orange County’s four trauma centers were on closure status for 188 hours in the second quarter of 1989, up from the 135 hours for the first quarter of the year, said Emergency Medical Services’ O’Rourke.

As Orange County’s population and traffic continue to increase, so has the number of trauma victims, hospital officials said.

Mission Hospital in Mission Viejo rarely goes on closure status, but the number of its trauma patients has soared, said Gary Fybel, senior vice president. The trauma center took care of 573 people in 1987 and 705 in 1988, he said. Through this June, it had treated 397, setting a record pace.

Insurance Requirement

One health care economist, Greg Bishop with the Trauma Resource Project in Irvine, has noted that a major part of the financial problem for trauma centers in the state is that although automobile accidents are responsible for about two-thirds of all patients sent to trauma centers, less than 10% of trauma center costs is reimbursed by automobile insurance companies.

Unlike many other states, he said, California has no requirement that a motorist carry medical insurance as part of his auto policy.

Public subsidies of the trauma network would probably offer the quickest salvation. Earlier this summer, however, Gov. George Deukmejian blue-penciled $100 million earmarked in the Legislature’s budget for emergency services statewide. Health officials hope that money raised through the recent passage of Proposition 99, which raised taxes on tobacco products, will eventually be released to the counties.

Even so, it can be expected that many health-care programs will stake a claim to the money.

David Langness, vice president of the Hospital Council of Southern California, said he expects that there will be no subsidies for trauma centers without a battle.

A 1987 survey by the council of 10 hospitals showed that the average loss per trauma patient was $4,386 among those classified as having no insurance.