Can the research process used by banks, restaurants, and grocery chains to determine future sites for development also help determine the best placement for trauma centers in Pennsylvania?
When Starbucks, Wal-Mart or Costco consider locations for future sites, they use geospatial analysis to select sites with the greatest likelihood for success. The process combines extensive geographic and demographic data with transportation options, consumer behavior, and the presence (or absence) of nearby competitors, among other data points, to achieve a competitive edge.
Most of Pennsylvania’s 40 accredited trauma centers opened well before geospatial analysis was possible. Located within hospitals, these specialty designed centers treat the most serious of injuries at any hour: traumatic car-crash injuries, gun shot and stab wounds, major burns, and traumatic brain injuries. Strategically locating trauma centers is critical because prompt access improves a patient’s odds of survival.
New research that analyzed trauma and health care cost data with hospital demographics, road networks, and U.S. Census data is helping the Pennsylvania Trauma Systems Foundation (PTSF) to institute policy changes that would add objective measurements to figure out the need for and placement of future trauma centers, rather than relying solely on financial and health care system decision making.
A research team led by the Penn Medicine Lancaster General Health Research Institute recently published three studies now in use by a Trauma System Development Committee formed by the PTSF. In the Commonwealth, trauma centers are accredited by the non-profit PTSF and receive a designation ranging from Level I to IV. The higher a center’s level, the more advanced and specialized its medical capabilities, as well as the depth and breadth of its research and training programs.
Michael A. Horst, PhD, MPHS, MS, director of Research Biostatistics for the Research Institute, explained that the studies tried to answer three questions about the state’s 27 adult Level I and II trauma centers that treat patients ages 15 and older:
- If we were to add up to six more trauma centers, where should they ideally be located?
- What would it look like if we began with a clean slate in Pennsylvania – no existing adult trauma centers – and used geospatial mapping to design a more effective and efficient trauma network?
- Are there regions in the state where trauma patients are underserved – treated by non-trauma centers for severe injuries –and, if so, what percentage of patients fall within this category?
“There’s been a lot of research focused on optimizing the care of patients at trauma centers, but few studies that sought to optimize the placement of trauma centers within an existing trauma system,” Horst said.
The studies yielded two relevant findings. First, roughly one-third of severely injured trauma patients are initially managed at hospitals without designated trauma services. Second, by using objective measures to place trauma centers optimally, the number of Level I and II trauma centers could decrease from 27 to 22 while still maintaining the current coverage area in PA in terms of travel time, as well as the volume/capacity requirements at each site.
Having too few or too many trauma centers within a region can have repercussions for patients and clinicians.
“A number of studies show that higher-volume trauma centers have better outcomes because staff members frequently use their training to treat severely injured patients. When an area has too many trauma centers, they can have a hard time achieving the patient volume that maintains staff competencies,” Horst said.
C. William Schwab, MD, Emeritus Professor of Trauma Surgery, noted that another, less-obvious negative effect a surplus of trauma centers present is the impact on the education, training, and research missions of academic medical centers and research hospitals with trauma programs.
“Creating the next generations of medical specialists, scholars, and scientific investigators is one of the most important responsibilities of academic medical centers,” Schwab said. Lower trauma volumes, he added, limit a center’s ability to allocated the sources necessary to adequately testing of new treatments – such as the ongoing work to test the effectiveness of using vasopressin versus normal saline during the resuscitation of severely injured trauma patients – or therapies that may improve survival rates or prevent disabilities.
Conversely, not enough trauma centers in an area can mean fewer patients are treated within the “golden hour” – the preferred window of time to provide trauma services that most improve the chances for patient recovery. Penn-led research published earlier this year showed that patients who sustain severe head injuries tend to have better outcomes if they are taken to a designated trauma center, but 44 percent of them are first taken to hospitals without those specialized care capabilities. Those results, the authors say, support the need for systematic changes to improve care.
In the new studies, the team analyzed the time to “definitive care” – how long it takes from the moment of injury to when a patient is delivered to a hospital emergency department. In areas like Philadelphia and its suburbs, the average time was around 15 minutes. In rural regions of the state like the Lewistown and State College area (in central PA) and DuBois (located 100 miles northeast of Pittsburgh), the average transport time was four hours or more.
While a solution may seem obvious – open a Level I or II trauma center where needed – the cost for facilities, equipment, and training is high, and it can be challenging to attract high-level surgical specialists like neurosurgeons to rural areas that lack the high volumes of urban or suburban centers. One possible answer might be to encourage community hospitals in areas of need to become lower level trauma centers.
“If we can use that 15 to 30 minutes of transport time to get a critically injured patient to a Level III or IV center, they can be stabilized, receive fluids and blood transfusions, and be prepped for transport to a major trauma center. The likelihood is that we can potentially save some lives,” Horst said.
The LG Health Research Institute has shared its findings at national trauma conferences, where a number of people from other states expressed interest in adopting a similar expansion model. The Institute is now looking at pediatric trauma centers and geriatric trauma data to determine if and how specific needs within those populations can be met more efficiently.
“The PTSF has acted responsibly to address where trauma centers are needed to further protect lives and seeks to find incentives for rural hospitals to develop trauma response programs and centers,” Schwab said. “This latest research advances that effort.”
Editor’s Note: The Pennsylvania Health Care Cost Containment Council (PHC4) supplied inpatient admission data for the years 2003 to 2015 and the PTSF supplied trauma admission data for the same time period.