As a 35 year veteran in physician recruiting and staffing in the surgical specialties, it seems within the last several years there has been an unprecedented movement within the hospital industry to establish new trauma centers or to upgrade designation status from Level III to Level II. This is particularly the case within the for-profit hospital chains. According to Kaiser Health News more than 200 trauma centers in 20 states have opened since 2009. In Ohio, where there are few investor owned hospitals, the trauma center count went from 22 verified centers to 42. So what’s the prize? Everyone knows that the payer mix for trauma patients is not so hot.

Here are a few things hospital executives are looking to gain:

1. Market Positioning – By obtaining or upgrading it’s trauma designation, the hospital is better positioned to market itself as a full-service hospital that can care for patients with all types of  illnesses to include the severely injured trauma patient.

2. Increases in Patient Volume – While the payer mix may not be so great, overall volume will provide increases in revenue. Also, trauma designation sometimes creates a watershed effect for elective, non-trauma surgical cases. Some of the trauma centers that have popped up have not been in underserved areas but in more suburban areas where they can attract paying patients.

3. Trauma Activation Fees – Any time an ambulance crew brings in a patient that is believed to be a trauma patient, the hospital as a trauma center, can charge a trauma activation fee to help cover the higher overhead it has to be a trauma center. Trauma activation fees range from $7,000 to $24,000.

Becoming a trauma center or upgrading status is not an overnight process. Trauma Center designation is strictly regulated. In order to become a level II trauma center, the facility must adhere to strict criteria to evaluate, manage and treat within the guidelines of trauma patient management. The process to become ACS verified or state designated can take quite a while. Trauma Center designation is a process outlined and developed at a state or local level.  The state or local municipality identifies unique criteria in which to categorize Trauma Centers.  These categories may vary from state to state and are typically outlined through legislative or regulatory authority. Due to the competitive nature of hospitals, opposition may occur for another facility to be verified as a trauma center and therefore as able to accept and manage trauma. Most likely it will come from the nearest Level I trauma center which is likely an academic medical center. The Trauma Medical Directors or Chiefs of Service in the Level I trauma centers may not feel that the competing hospital can provide the resources necessary to provide optimum care. As well, they may think it is a duplication of services that are not needed in close proximity if both a level I and level II trauma center are available. The market must provide an adequate amount of trauma to facilities in close proximity to insure the number and amount of cases needed in a timely fashion to fulfill requirements needed for trauma center designation. This may be difficult if both places are competing for time, surgical skills and numbers of cases.

This brings us to the orthopedic surgeon. Yes you need trauma surgeons, neurosurgeons, vascular surgeons and so on, but the specialty that is key to treating the trauma patient is the ortho trauma surgeon. A trauma designation must include the availability of an orthopedic surgeon to provide care within the required time limit for each trauma designation(within 30 minutes for a Level II).

According to the AMA Masterfile there are 235 practicing physicians with a self-designated primary specialty of ortho trauma and 287 with ortho trauma as a secondary specialty. There are roughly 50 fellowship training programs who graduate 75-80 fellows a year. Orthopedist right out of ortho trauma fellowship usually have a strong preference to join a large orthopedic group or join the faculty in an academic medical center that has Level I designation with residents and teaching and research opportunities.  This assures an active and robust practice with the ability to use the skills and experience learned and needed to be performed to maintain trauma specialty services. A trauma surgeon must have hands on experience to maintain qualification for continued orthopedic trauma care. The benefit of closely working with experienced orthopedic trauma surgeons is also a benefit of being in a larger center.

There are not nearly enough of them to go around, whether they are practicing physicians or coming out of fellowship, so it should not be expected that a newly designated or upgraded trauma center would be able to achieve 24/7/365 coverage from fellowship trained orthopedic traumatologist.  It is also quite a stretch to rely on orthopedist on the on-call panel to optimally take care of these patients, particularly when it comes to patients with acetabular/pelvis fractures. Community hospital orthopedist are generally opposed to doing this kind of work for a variety of reasons. Due to the nature of this injury, generally high energy, the community hospital orthopedic surgeon is generally not comfortable treating high energy pelvic fractures. These types of fractures also are frequently accompanied by other high energy fractures and dislocation of other extremity bones and abdominal, spine, and head injuries.

So what should you do if you’re an orthopedic surgeon and the hospital comes to you with a plan to get in the trauma game? What should you do if you are a hospital leader with aspirations for becoming a trauma center or in elevating your current trauma center designation level?

Remember the Following:

Twenty-Four (24) hour immediate coverage by general surgeons as well as coverage by the specialties of orthopedic surgery, neurosurgery, anesthesiology, radiology and critical care is a must. Furthermore, the facility, hospital, or institution need to provide trauma prevention and continuing education programs for staff. This includes CME that insures required number of hours dedicated to trauma management. All physician and surgeons covering that hospital must include trauma CME’s in their ongoing medical education portfolio. This CME requirement and demonstration of trauma interest is an element of the program that will open to evaluation and auditing.

The most important factor is the comfort the orthopedic surgeon has with dealing with emergency and high energy orthopedic injuries. If orthopedic surgeons do not have a history of managing trauma patients, further hands on classes, lectures, or cadaver labs may have to be considered if trauma patients will be expected to be safely managed by inexperienced orthopedic surgeons.

Orthopedic Surgeons

If the hospital has approached you or one of your orthopedic colleagues about this or you’ve “heard it through the grapevine”, be cognizant that it may very well already be in their strategic plan and their going to move forward with or without your support. As a practicing orthopedic surgeon in presumably, a hospital with an already busy emergency department, you are in a position to have significant input into how patients are triaged and referred. Lay the groundwork to have the orthopedic trauma triaged and shared with the orthopedic traumatologist who comes on board. You and your colleagues could see a portion of the trauma, stabilize the severe ones and hand them off to the orthopedic traumatologist . A triage plan may also be considered for transfer to a level I center for a higher level of care and expertise if needed.

Hospital Leaders

Once you’ve reviewed the criteria in your state for seeking your first designation or to increase your designation level, you must then consider whether or not you have the support of the current medical staff, particularly the orthopedic surgeons, neurosurgeons and general surgeons. This support is key and you shouldn’t overlook it. If you don’t have it, you must determine whether or not you can recruit the specialist necessary to maintain a trauma center and determine what it’s likely to cost. Look for a win-win. You may be able to come up with an arrangement to partner with the local orthopedists with a one or two additional fellowship trained orthopedic trauma surgeons or bring on an orthopedist who is not fellowship trained but has experience in and enjoys doing complex pelvic fracture work. This is not an overnight process. Also, determine what role your hospital can realistically play in the local trauma system and become a part of it. You will likely get your share of trauma patients, but you do have to have the designation to receive the trauma activation fee, and you have the costs associated with paying the surgeons and having an OR ready 24/7.