Not all hospitals are created equal. The more serious or uncommon an injury or condition is, the larger the hospital required is. Because not all hospitals are equipped to handle every possible problem, often patients will need to be transferred, sometimes by air depending on the urgency, to a larger and better equipped (and funded) institution.
Though, when individual cases are transferred is determined by the doctor in the moment, and thus subject to variation; there is an overall system which determines which institutions ship what cases where. Let’s take a look at that system, and how its organization can affect a trauma patient's survival chances.
Trauma centers, which are hospitals equipped to handle physical trauma cases like car crash trauma and anaphylactic shock, are divided into five tiers by the American Trauma Society, and evaluated by the American College of Surgeons. As the level increases, the center becomes better equipped to handle a variety of cases.
Note that centers will often have different levels of care for different groups, meaning a Level I Adult facility might only be a Level II Pediatrics facility, and a Level IV Oncology facility.
Level V trauma centers are very small, only able to provide “initial evaluation, stabilization and diagnostic capabilities”, and often transfer patients to higher level centers. However, Level V facilities still offer a relatively large amount of care, and will always include the following:
Basic emergency department facilities to implement ATLS protocols.
Available trauma nurse(s) and physicians available upon patient arrival.
After-hours activation protocols if the facility is not open 24-hours a day.
Transfer agreements for patients requiring more comprehensive care at a Level I through III Trauma Centers.
Level V centers sometimes also have the ability to provide surgery and critical-care services, though often only for a limited range of traumas (due to surgeries often being done by a doctor, and not a general surgeon)
Level IV trauma centers are similar to Level V centers, include a few key additions which make them more independent:
24-hour laboratory coverage
Active outreach efforts for its referring communities
Level IV centers still often transfer and refer patients to higher level hospitals, however.
Level III trauma centers are a big jump away from Level IV centers, mostly due to the fact that they can provide prompt (usually) on-site resuscitation, surgery, and intensive care 24-hours a day, every day. Level III centers are the first level which receive transfers, and the buck usually stops there. Patients requiring specialized surgeries or specialist care can be transferred higher up the chain, however.
Major elements of Level III centers are:
24-hour availability of general surgeons and anesthesiologists.
Provides back-up care for rural and community hospitals
Offers continued education for nurses, allied health professionals, and/or trauma teams
Simply put, Level II trauma centers are able to initiate definitive care for any and all patients.
Specialty surgery, including orthopedic surgery, neurosurgery, anesthesiology, radiology, emergency medicine, and critical care
Trauma prevention programs
Education programs for staff
However, non-urgent specialty surgery, usually tertiary care such as cardiac surgery, hemodialysis, and microvascular surgery, may be referred to a Level I center.
A Level I trauma center is capable of providing total care for every aspect of injury, from prevention to rehabilitation. Level I trauma centers act as regional tertiary care facilities as well.
Level I trauma centers include, along with everything that Level II centers and below offer:
Plastic surgery, oral surgery, maxillofacial, and pediatric care
Substance abuse screening and patient intervention
Organized teaching and research efforts, including new innovations in trauma care
“Leadership in prevention, public education to surrounding communities”
Level I trauma centers also have an annual minimum requirement of volume of severely injured patients.
Distribution of Trauma Centers:
The distribution of trauma centers correlates fairly highly with population, predictably. However, this often means that patients in rural areas, regardless of wealth (not that wealth should play a role in determining access to healthcare), will often have to travel long distances if they require specialized surgery. This unfortunately compounds with the fact that less populated areas tend to be more spread out by default, meaning that a patient in South Dakota might need to be flown across the state for care in an emergency, meaning more time between the trauma event and surgery. Around 30% of the U.S population depends on air transport for urgent medical care.
Whether or not this distribution issue is a problem which can ever be totally solved is a difficult question, one for statisticians and the government, but there is one compounding socio-economic issue which can be solved right away: who pays for medical transport? The patient does, in the United States. Air ambulances can cost an enormous amount of money (read this article to see some frightening examples), and aren’t totally covered by insurance. This major economic disincentive can force providers to make tough calls about patients who request no transport. This pressure could be alleviated by an overhaul of the U.S’s healthcare payment system.