History and Background:
Trauma is a disease of epidemic proportions. Each year, over 140,000 American's lives
are ended - suddenly, unexpectedly, brutally - by this killer. It has been aptly called
the last major plague of the young, for trauma kills more Americans between the ages of
one and thirty-four than all other diseases combined. But trauma is more than a plague of
the young: Trauma is the leading cause of death for all people under age forty-four, and
the leading cause of disability for all people under age sixty-five.
While health and illness care, in general, have made extraordinary advances during the
last forty years, the battle to abate the trauma epidemic has seen only limited success.
Three major factors account for this.
First, the medical specialty of emergency medicine and trauma care is relatively new.
The concept of early field intervention and immediate transport to an acute care center
with highly skilled health care professionals prepared to provide early, definitive care
was only recently developed, a by-product of the Vietnam conflict. Moreover, medical care
is limited: Regardless of advances in technology and techniques, a surgeon can only do so
much to save a child with a flail chest, a mother with a crushed spine, a teen struck in a
drive-by shooting.
Second, injury prevention, a powerful weapon in the fight against trauma, suffers from
a lack of drama and immediacy. Too often the blaring sirens and flashing lights of the
emergent, acute care component of trauma overshadow the seemingly mundane arena of
prevention. Too often cavalier, fatalistic attitudes that "accidents" are
"inevitable" justify inaction and create a cycle that feeds upon itself. Yet,
from changes in product safety to changes in personal behavior, prevention is clearly one
of the most effective and least costly means for reducing the occurrence of trauma.
And third, the development of a trauma care system - a system which assures that the
required resources are available and the necessary infrastructure is in place to deliver
the "right" patient to the "right" facility in the "right"
amount of time - entails broad consensus and cooperation among divergent groups and around
complex logistical, political, financial, legal and medical issues. In some states,
attempts to develop such a system have succeeded; in others they have failed.
Yet, given the nature of the disease, a comprehensive trauma care system which includes
a strong injury prevention component holds the most promise for curbing this brutal
epidemic. Thirty to forty percent of all trauma deaths occur within hours of the injury,
usually from shock and/or internal bleeding. Virtually all of these deaths are considered
inappropriate and preventable, and would not occur if an organized trauma system were in
place. Moreover, all trauma deaths, and particularly those which occur within minutes of
injury and for which there are no effective medical treatments, could be avoided through
appropriate injury prevention actions.
Washington State is continuing its tradition of being in the forefront in confronting
this epidemic. In 1990, far-reaching legislation was adopted which called for the
development of a comprehensive statewide trauma care system. This legislation was the
culmination of a series of initiatives which began in the late 1960's with the University
of Washington pioneering the development of paramedic training programs; continued through
the 1970's with the establishment of legislatively-mandated minimum standards for
prehospital providers and services, and certification for paramedics and other advance
life support personnel; and concluded in the late 1980's with the completion of the
"Washington State Trauma Patient Tracking Study," and the development of the 1990
Washington State Trauma Project: A Report to the State Legislature.
The key components of this 1990 legislation, the Trauma Care Systems Act,
include:
· Clear lines of authority and responsibility;
· Designation of services;
· Trauma Care services;
· Verification of Prehospital Trauma services;
· Field triage criteria development;
· Regional planning and implementation;
· Cost containment considerations;
· Integration of trauma/injury prevention;
· Trauma registry development;
· Establishment of regional quality
assurance/improvement programs;
· Integration of trauma rehabilitation services; and,
· Evaluation of system effectiveness.
In addition, particular attention is being focused on the needs of rural and American
Indian communities; on integrating the continuum of care from prevention and first
responder agencies to the acute care treatment centers and through rehabilitation
services; and on empowering the regions within the state to identify and address the
unique needs, circumstances and conditions they each must face.
The closures of trauma centers in California and Florida have attracted much national
attention. In part, these closures reflect a necessary evolution and refinement of the
trauma systems in those states. More significantly, however, they demonstrate the
necessity for careful consideration of the economic consequences of trauma care and trauma
system development. The fundamental prerequisite for the development of a successful
trauma care system is our society's resolve to commit the resources required to get the
job done.
The integration of the trauma system with the existing EMS system is being implemented;
community-based prevention projects have been implemented statewide; the initial
designation of trauma care facilities is completed with geographic coverage statewide; the
implementation of the statewide trauma registry is well underway, and regional quarterly
assurance/improvement programs are being initiated. Stable and continuous funding is vital
to this crucial phase of system development.
The horror of trauma is not in the mangled heap of twisted steel and blood; it is in
the eyes of a mother and father who have just lost their child. And the crime of trauma is
not just perpetrated by gang members or drunken drivers; it is also perpetrated by a
society that would knowingly deny and neglect this cruel epidemic.
State
Authority and Responsibilities
Trauma - the leading cause of death for all people under age forty-four and the leading
cause of disability for all people under age sixty-five - is a disease of epidemic
proportions. Yet, between thirty and forty percent of trauma deaths would not occur if an
organized trauma system were in place. Washington State has developed and is implementing
such a system.
The Washington Emergency Medical Services and Trauma Act of 1990 declared that a trauma
care system, one which delivers the "right" patient to the "right"
facility in the "right" amount of time, would be cost effective, assure
appropriate and adequate care, prevent human suffering, and reduce the personal and
societal burden resulting from trauma. In addition, the statute acknowledged prevention as
a powerful weapon in the fight against trauma, and called for the integration of injury
prevention programs in the development of the trauma system.
The statute also called for a biennial plan to be made available to assure the orderly
and systematic implementation of the trauma system. This document - the 2nd biennial plan
- provides the vision, goals and key components fundamental to a trauma system and,
together with each region's plans, outlines the specific actions needed to implement and
improve the statewide trauma care system.
Finally, in fulfilling the mandates of this legislation, four major groups of
participants have been assembled: The Department of Health's Office of Emergency Medical Services
and Trauma System, the Governor's Steering Committee on EMS and
Trauma Systems Development, the EMS Licensing and Certification Committee, and the
EMS and Trauma System Regions.
