Thursday, February 21, 2002
Trauma center plans in limbo
Shortage of specialists makes some certifications uncertain
By Tim Bonfield
The Cincinnati Enquirer
Come Nov. 3, Ohio's new statewide trauma system is supposed to start saving lives by routing more severely injured people to properly staffed trauma centers.
But in Greater Cincinnati, a short supply of doctors willing to cover emergency cases has played havoc with trauma center plans at several suburban hospitals.
For now, University Hospital is the only adult hospital in Greater Cincinnati to meet the new law's requirement to be verified as a trauma center by the American College of Surgeons. Hospital officials say the area will be lucky to have two more ready by November: Bethesda North in Montgomery and maybe Mercy Hospital Fairfield.
By comparison, Cleveland already has six verified adult trauma centers, according to the Ohio Committee on Trauma. Columbus and Toledo have four each. Dayton has three (counting one in nearby Troy).
The problem in Cincinnati: Years of lower-than-average insurance reimbursement for specialist physicians have made key doctor groups unwilling to take on the round-the-clock duty that the state trauma law requires.
Trauma cases represent the most severe 8 percent to 13 percent of all injuries that come to hospital emergency rooms. Trauma cases include victims of car wrecks, gunshots, burns and severe falls.
Some hospitals are struggling to secure commitments from neurosurgeons. For others, a wide range of general surgeons, orthopedic surgeons and others have been reluctant to support hospital trauma center plans.
We've been saying for some time now that specialist recruitment and reimbursement has been a serious problem. One of the first places that the average person is likely to see the impact is in emergency care, said Russell Dean, executive director of the Academy of Medicine of Cincinnati.
Greater Cincinnati hospitals already have reported record numbers of hospital diversions, or situations in which hospitals ask life squads to take emergency cases somewhere else because they lack enough nursing support or available beds in key units to take on more patients.
Now the requirements and deadlines imposed by the trauma system law passed two years ago threaten to further complicate emergency care.
The difficulty here is the scarcity of these key surgical subspecialties. It is unclear how the trauma system is going to work out from a practical standpoint, said Tom Urban, president of Mercy Fairfield. The shortages are affecting all of Cincinnati's hospitals. We're having similar struggles.
Two years ago, emergency medicine experts led a push to pass a trauma system law in Ohio, joining at least 28 states and the District of Columbia that already have similar systems.
According to the Ohio Department of Public Safety the agency coordinating the new system the intent is to save lives and reduce disability by getting the right patient to the right hospital at the right time in the right manner.
Starting Nov. 3, life squads will be required to take all trauma patients directly to an officially designated trauma center, except in specific circumstances such as bad weather or excessive travel times.
To be qualified to treat trauma patients, hospitals must be verified by the American College of Surgeons. Hospitals can seek one of three levels of trauma center status.
The levels primarily reflect the types of specialist care required to be immediately available to trauma patients, with Level 1 being the most extensive. For example, a Level 1 trauma center must have cardiac surgeons on hand 24 hours a day, a skill that is desired but not required for Level 2 and not required at all for Level 3.
Experts in Cincinnati initially expected several suburban hospitals to make the changes needed to meet American College of Surgeons standards.
Last year, Bethesda North Hospital one of the area's busiest suburban emergency departments announced plans to pursue Level 2 trauma center status.
Initial contenders for becoming Level 3 trauma centers included Jewish Hospital in Kenwood, Mercy Fairfield, Mercy Anderson and possibly one of the two Mercy Franciscan hospitals in Mount Airy and Western Hills.
Some also hoped at least one Northern Kentucky hospital would seek trauma center designation, even though Ohio's law would not apply.
But in November, Jewish Hospital disbanded its trauma services and announced it would not seek Level 3 status.
At Bethesda North, officials now say they are not sure they can meet the Level 2 requirements. Among the Mercy hospitals, plans for multiple trauma centers have dwindled to one and even that effort remains uncertain. And so far, no Northern Kentucky hospital has moved to seek trauma center designation.
We'd like to have a trauma center designation in Fairfield, if we can find the resources to do it, Mr. Urban said. It's not a done deal. We hope to have a clearer picture within 30 to 45 days.
At Bethesda North, hospital officials have not been able to nail down a required commitment for neurosurgery coverage.
Without neuro and spine coverage, we cannot be a Level 2 center, said Dr. Anthony Borzotta, trauma services director for TriHealth, the hospital group that runs Bethesda North.
The pay problem
Whether or not they plan to be trauma centers, several Greater Cincinnati hospitals have struggled recently to convince specialists who typically are not hospital employees to cover emergency care.
For years, hospitals expected doctors to take turns covering night and weekend ER shifts as a condition of obtaining hospital privileges.
But as reimbursement rates for doctors have dwindled in Cincinnati, some have left town for better pay and fewer new ones have been moving in. Reimbursement rates vary widely by speciality and by insurer, but doctors say reimbursement rates in Cincinnati frequently rank among the lowest in the region. Some doctors have been able to significantly boost their income simply by moving to Dayton, Mr. Dean said.
Doctors saying no
Increasingly, doctors who remain in town are saying no to increased emergency room duties, such as those required to be a trauma center.
The Mayfield Clinic and Spine Institute is Cincinnati's largest neurological specialty group. It includes Dr. John Tew, an internationally prominent neurosurgeon.
Despite a powerful reputation, the group has so much trouble recruiting new physicians to town that it struggles to maintain its current hospital obligations much less expand them, said Mike Gilligan, president and chief executive at Mayfield.
Ten years ago, it was much easier to recruit to Cincinnati, Mr. Gilligan said. A decade ago, we had 30 adult neurosurgeons in the area. Now, there's 20. And of them, nine are aged 60 or older.
Yet local demand for neurosurgery has gradually increased, Mr. Gilligan said.
I still think (Greater Cincinnati hospitals) still provide well-above-average care. But the quality is moving from A to A-minus, Mr. Gilligan said. And the trend isn't going in the right direction.
Dr. Thomas Saul, a neurosurgeon with Mayfield, said his group has been working for two years to encourage establishing a trauma center at Bethesda North. The issue is complicated because supplying the surgeons to cover Bethesda North given the limited supply of neurosurgeons in town would require moving nontrauma neurosurgical services away from Good Samaritan Hospital, he said.
It's not as simple as a hospital administrator saying, "We can't get neurosurgeons to cover trauma.' If TriHealth wants to be in the trauma center game, then it has to do what it takes to do it right, Dr. Saul said.
Some trauma centers in Ohio and nationwide have started paying surgeons to take on-call shifts. Some Level 2 trauma centers in Ohio pay $800 to $1,200 for a night shift and $900 to $1,600 for a weekend shift in addition to whatever fees the doctor can collect, Dr. Borzotta said.
Such payments have not been common in Cincinnati. And budget-pinched hospitals have been extremely reluctant to start down that path, Mr. Urban said.
We're not to that point yet, but that may be something we have to face, Mr. Urban said.
Changing trauma rules
Historically, life squads have taken injured people to the closest hospital emergency department. Even under this informal system, many seriously injured patients already go straight to University Hospital.
In fact, University Hospital treats more than 2,100 trauma cases a year, including patients from Ohio, Kentucky and Indiana.
Critics of the system have argued for years that more lives could be saved if more patients went straight to trauma centers, and if others could be transferred to trauma centers faster.
We've been preparing for this for a long time. We were among the ones who thought this was necessary legislation, said Dr. Jay Johannigman, a top trauma surgeon at University Hospital who sits on a statewide board formed to develop trauma system standards.
Like Cleveland or Columbus, Greater Cincinnati ideally should have several trauma centers including verified ones in Northern Kentucky and Southeast Indiana, Dr. Johannigman said. That so few have sought trauma center designation has been somewhat disappointing, but not surprising, he said.
In this state, a lot of people have said, "We've been functioning as a trauma center for 20 years.' Now that the deadline is approaching, they're finding out how much is really involved, Dr. Johannigman said.
Trauma victims in Greater Cincinnati will get better care if Bethesda North, Mercy Fairfield and others actually carry through with their plans. But if they can't, University Hospital will carry on, Dr. Johannigman said.
Certainly we are managing the volume we have now, Dr. Johannigman said. Over the next 12 months, we're expecting a 15 to 20 percent increase in volume and we're taking steps to accommodate that.
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