Mississippi Revitalizes the State Trauma Care System

 

Unintentional injury is the leading cause of mortality both nationally and for Mississippians aged less than 45 years. Mississippi ranks third in the nation for unintentional injury deaths. Research shows formal trauma systems reduce traumatic injury mortality. Formal trauma systems are also important first lines of defense for reducing deaths caused by natural disasters, terrorism events, and pandemics. States have actively implemented policies to strengthen formal trauma systems over the past 30 years. Mississippi began developing a formal trauma system in 1991.

The Mississippi Firefighters Memorial Burn Center, the only burn care specialty facility in the state, closed in 2005. Two reasons were given for the burn center closure: uncompensated care and inadequate specialist coverage. The Governor formed a Burn Care Advisory group to review and make recommendations concerning burn care in Mississippi. In 2006, legislation was passed to transfer the remainder of the burn care funds from the Mississippi Firefighters Memorial Burn Center to the Mississippi State Department of Health. However, burn trauma is a small fraction of the nearly 18,000 trauma cases occurring in Mississippi annually (Figure 1). The burn center closure was symptomatic of problems occurring within a “diseased” statewide trauma system.figure-1-ms-trauma-and-burn-cases-2006-for-web-558x640

Informing The Policy Debate

The Center for Mississippi Health Policy undertook research during 2006 in order to inform the policy debate regarding the statewide trauma system. Statewide trauma leaders were interviewed and the trauma system history, operations, legislation, funding, as well as outcomes and best practices of other states were reviewed.  The resulting report titled:  Mississippi Trauma Care System:  Life Saving Care is No Accident, was disseminated to stakeholders and policy makers during 2007.  The Center report found that nationally, trauma systems struggled to meet patient demand and center closures were increasing. The Institute of Medicine emphasized fragility of state trauma systems in its report, Future of Emergency Care. Mississippi’s trauma system was at mid-maturity (Figure 2), as were the majority of other state systems.  However, Mississippi’s trauma system had stalled at mid-level development and was on the verge of collapse unless uncompensated care and provider shortages were not addressed expediently.

Figure 2:  Trauma System Characteristics for Mature Systems & Mississippi, 2005

Trauma System Characteristics States with Mature Trauma Systems Mississippi
Pre-Hospital Categorization & Triage
  Standard Triage Protocol Yes Yes
Standard Training Program Yes Yes
Compliance Monitored Yes No
 Inter-Hospital Transfer Arrangements
  Standard Transfer Protocol Yes No
Policy Specifies Patients to Transfer Yes No
Emergency Department Compliance   Monitored Yes No
 Trauma Registry Data Submitted by
  Trauma Centers Yes Yes
Non-Trauma Centers Yes No
  Trauma Advisory Committee Yes Yes

 

Source:  Man, Mackenzie, Teitelbaum, Wright, and Anderson, 2005.

Mississippi taKES ACTION

During the 2007 Legislative session, Senate Bill 2863 was enacted. This legislation mandated creation of a Trauma Care Task Force charged with reporting the status of the statewide trauma system and burn care to the Governor and Legislature by December 2007. The Trauma Care Task Force included trauma center administrators and trauma care specialists, as well as Mississippi Legislators from both Senate and House chambers.  Trauma Care Task Force members requested assistance in compiling their report from the Center. The Trauma Care Task Force Final Report was disseminated to the Governor, Senate & House Public Health Committees, as well as other stakeholders during late 2007 along with an Issue Brief summarizing the report.  The Trauma Care Task Force findings did not change significantly from the Center’s initial trauma report:

  • The state’s trauma system was at near collapse, with large areas lacking access to specialized trauma care during the “golden hour” (first sixty minutes after sustaining traumatic injury), due to many hospitals halting trauma system participation (Figure 3);

 Figure 3:

  • Funding was inadequate for statewide trauma system viability;
  • The system’s decline was primarily due to uncompensated trauma care and provider shortages, as was the case with the burn center closure;
  • Burn victims’ families struggled to pay for out-of-state travel costs, although the majority of the burn care fund had not been expended since the burn center closure in 2005; and
  • The state was no longer a leader in trauma system development but had a stalled and deteriorating system.

The Trauma Care Task Force recommended two funding mechanisms to sustain the statewide trauma system:

  • fees and assessments targeting risky behaviors associated with trauma care; and
  • a “pay or play” provision, whereby trauma centers capable of providing care that chose not to do so were assessed a fee to be deposited into a fund to support trauma centers that were participating to the extent of their capabilities.

Legislation was enacted during the 2008 legislative session via House Bill 1405 to implement many of the Trauma Care Task Force recommendations. The funding provisions of House Bill 1405 were projected to add approximately $30 million to the existing annual trauma and EMS system revenue of $8 million. The bill became effective on July 1, 2008, adding multiple provisions to the current trauma statute:

  • a “pay or play” funding provision;
  • a series of mechanisms  to generate additional funds for trauma care from fees and assessments in areas related to trauma;
  • a provision for Level I trauma centers from surrounding states caring for Mississippi trauma patients to be eligible to receive trauma care funds for uncompensated care;
  • a mandate whereby members of the system oversight council must continue to serve until replacements are named by the Governor; and
  • an authorization for the Mississippi Department of Health to reimburse victim families for out-of-state travel expenses from the burn fund.

The “pay or play” regulations promulgated by the Mississippi State Department of Health, outlined procedures by which licensed acute care facilities would be assessed by the Department, based on the characteristics of each facility, for the level of trauma care each could contribute to the system.  Levels of trauma center care have historically been based on modifications of the American College of Emergency Physician and American College of Surgeon guidelines (Figure 4), with Level I being the highest tier of trauma care and Level IV being the lowest tier.  A licensed acute care facility, once designated, can choose to participate in the trauma care system and be entitled to reimbursement for uncompensated trauma care.  Otherwise, the facility will be assessed a fee if choosing either to opt out of participation or to participate at a lower level than deemed capable.  These “pay or play” fees are deposited into the Trauma Care Systems Fund to reimburse properly participating trauma centers for uncompensated trauma care.

Figure 4:  Trauma Center Designation Levels

Level I Level II Level III Level IV
Emergency Department Emergency Department Emergency Department Emergency Department
Full-Service Surgical Suite Full-Service Surgical Suite Continuous General Surgical Coverage Initial Evaluation & Assessment of injured patients
Intensive Care Unit Intensive Care Unit Continuous Orthopedic Coverage Most Patients Require Transfer to a Higher Level Trauma Facility
Diagnostic Imaging Diagnostic Imaging Transfer Agreements with Level I & II Trauma Centers for Patients Requiring a Higher Level of Care Must Have Transfer Agreements in Place with Level I, II, & III Trauma Centers
Residency Program Act as a Referral Facility for Level III& IV Trauma Centers Referral Center for Level IV Trauma Centers
Ongoing Trauma Research Transfer Agreement with Level I Trauma Center for Specialty Care
Twenty-Four Hour Trauma Service
Act as a Referral Facility for Level II,III, & IV Trauma Centers

 

Source:  Mississippi Department of Health, Bureau of Emergency Medical Services Annual Report, 2005

Summary

An adequate formal trauma care system is critical to saving lives endangered by traumatic injuries. Policymakers in Mississippi identified the problem of a deteriorating system, reviewed best practices and policies implemented in other states, and took action to address the issue. Mississippi recognized the seriousness of the problem and took steps to revitalize the system. Mississippi once again moved to the forefront of trauma system development.