When Alabama ranked near the bottom of a 2006 healthcare study by the American College of Emergency Physicians, state healthcare leaders took action to begin addressing the problem, which State Health Officer Don Williamson attributes to a lack of funding directed toward trauma care. The study ranked Alabama 49th in the nation for both board-certified emergency physicians per 100,000 people and trauma centers per 1 million people, a mismatch for the state’s other ranking by the Centers for Disease Control and Prevention, which lists Alabama as having the fourth-highest highway trauma death rate in the United States. Legislation to establish a statewide trauma system was approved in June by Gov. Bob Riley giving the Alabama Department of Public Health (ADPH) oversight of the new system. It also created an advisory council of medical professionals to work with the ADPH in establishing the most appropriate system for our state and ensuring its continued operation, according to Rosemary Blackmon of the Alabama Hospital Association. With only one Level 1 trauma center for adults in the state at UAB Hospital, the new system will help provide improved trauma care statewide and take some of the burden off of UAB, which has had to take on more cases as other area hospitals closed trauma practices because of rising costs. “Trauma is an issue nationally as well as at state and local levels. Being a state organization, our mission is to take care of the citizens of Alabama,” said Dr. Michael Waldrum, chief executive officer of UAB Hospital. “As other hospitals get out of the business, we’ve had to accommodate that care, and it has added significant stress to our organization.” Waldrum says there are a number of costs related to running a trauma system, such as the high price of staffing the center with the level of physicians needed to handle critical patients, including trauma surgeons, neurosurgeons, orthopedic surgeons and other critical care physicians and staff. He says that his trauma center has been running at 70 percent capacity to ensure appropriate care for patients, and that level of staffing has added to the strain on the hospital’s pocketbook. “We’ve dealt with it the best we can and have tried to look at the problem from a community perspective. Our leaders have met with other healthcare professionals and decided it’s not just a UAB problem; it’s a community problem. That’s what led to the legislation,” explained Waldrum. Elements of the statewide trauma system will also include centralized dispatch for participating trauma centers and emergency medical services, a statewide trauma registry and a State Trauma System Fund. Williamson is optimistic about the success of the system because it will ensure that patients are routed to the closest hospital that can handle their injuries. “We will end up with a system where 90 percent of patients never get in the trauma system, and lesser injuries, which are about 92 percent of patients, will stay at local hospitals,” he said. “The system will prevent unnecessary transfers but at the same time will facilitate transfer to a higher-level center if needed.” A successful model for the system already exists in the Birmingham Regional Emergency Medical Services System (BREMSS), which will be used as a template for the statewide system. Williamson says that the state is providing $1.3 million to expand the existing framework throughout the state, including a centralized communication system, the expenses for statewide and regional councils, the statewide trauma registry and a process for distributing funds from the State Trauma System. Where funds will come from for the ongoing service has not yet been determined, according to Danne Howard of the Alabama Hospital Association. “We currently have the financial ability to operate central dispatch, and additional funding would help hospitals maintain the resources necessary to participate in the system, such as physicians and equipment,” said Howard. Williamson says that additional funding will be needed to pay for on-call physicians, to care for uninsured patients and to intensify hospital participation. “We estimate that the annual cost will be about $40 million,” he said. “The money isn’t there right now, and we will have to find funding to keep it going.” Howard pointed out that future revenue will have to come from new sources but could not say whether those sources would include additional taxes or fees. “It’s yet to be identified, but I assume we might have to look at that in the future,” Howard added. “When we get it done, it will be the only system like it in the nation. We’re excited about the future possibilities.” Building on the existing award-winning system, BREMSS officials have already begun the process of expanding its framework into other parts of the state. Executive Director Joe Acker says they have started in north Alabama where they’ve already completed all hospital site visits and have identified 14 hospitals that will participate in the system. Among those hospitals, there will be one Level 1 trauma center at Huntsville Hospital, four Level 2 centers and nine Level 3 centers. “We have moved to the planning process for East, West and Southeast Alabama and have been in contact with the Emergency Medical Service agencies there to build a trauma system in those parts of the state,” Acker said. Acker pointed out that one thing that made BREMSS successful in the Birmingham region was its initial requirement that the regional system be financially stable for hospitals and physicians. “While other hospitals have been getting out of the trauma business, we’ve been countering that trend in Birmingham. We had 10 hospitals in our trauma system when we started 11 years ago, and we still have 10 hospitals,” he said. “One thing we’ve done is to offer hospitals optimal economic flexibility to do what’s best for their hospital and doctors.” Acker said they also protect the Level 1 centers since they take the most critical patients. They don’t want to overload resource capabilities because that creates a hardship on critical patients and other patients if there is a backup because of trauma cases. “At a Level 1 center, resources can overflow periodically if a major problem occurs, but we also realize that when a hospital reaches the saturation point because of high volume, quality of care may decrease. It’s to the patient’s and hospital’s and ultimately the system’s advantage to avoid resource overload on a Level 1,” Acker said. Based on BREMSS’ success, Acker feels that the statewide system will also be successful if hospitals work together. Other states have tried to establish such a system but haven’t succeeded. “For 11 years, BREMSS has been 100 percent voluntary, non-legislatively mandated and 100 percent supported with local funds from hospitals and other agencies,” he said. “That’s the way we make things work, and everybody has a stake. We must build the system from the ground up, and healthcare providers all have to work together so it’s feasible from a care perspective for the patients as well as the hospitals and physicians. They haven’t been able to do that in other places; it takes a lot of work.” Waldrum is optimistic about the benefits of the new system. He sees it as a community of physicians and hospitals coming together to solve a problem. “The Alabama Hospital Association came together to work on a community issue,” he said. “I feel positive about the legislation and am appreciative that it passed. I am hopeful that it will help to offset some of our costs so we can continue to care for critical patients at UAB.” November 2007