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As trauma centers multiply, rural coverage lags

West of the Susquehanna River, long distances separate rural communities from accredited trauma centers

It’s called the golden hour.

For trauma victims, reaching treatment as quickly as possible — 60 minutes is the common benchmark — has long been seen as critical to survival.

But in some parts of central and northern Pennsylvania, the golden hour remains beyond reach. Rugged terrain and long distances separate rural communities and isolated areas from accredited trauma centers.

More than 30 of Pennsylvania’s 40 trauma centers are on the eastern side of the state. They stretch in an arc from Bradford County in the north, down to Philadelphia and west to Dauphin and York counties. About 80 percent of them are east of the Susquehanna River.

Unlike other hospitals, a trauma center must have available at all times a team of health care providers trained in the care of severely injured patients, and must adhere to standards set by the state’s approved accrediting agency, the Pennsylvania Trauma Systems Foundation.

West of the midstate, more than 150 miles of highway and mountains had separated the region from the next nearest trauma center, at UPMC Altoona in Blair County.

That will change today, with the accreditation of a Level II trauma center at Geisinger Holy Spirit, in East Pennsboro Township. The hospital’s $32 million investment in Cumberland County aims to bring more people within golden hour range.

“The trauma center at Geisinger Holy Spirit will save critical minutes for area patients suffering from severe, life-threatening injuries,” said Kyle Snyder, the hospital’s chief administrative officer, adding that it will bring trauma care closer for about 500,000 residents of western Cumberland, northern York, Perry, Franklin and Adams counties.

While it is expected to benefit some rural central and southcentral Pennsylvania communities, the center is still only three miles west of downtown Harrisburg. It is about 30 miles northwest of WellSpan York Hospital’s Level I trauma center in York County, and about 20 miles west of Penn State Health Milton S. Hershey Medical Center in Dauphin County — another Level I facility — yet still more than 100 miles from Altoona.

That cluster of trauma centers here in the midstate underscores vital questions facing the health care industry in Pennsylvania and nationwide: How many more trauma centers are needed? Where should they be built?

Some states have witnessed a proliferation of trauma centers in proximity to one another in urban areas, creating competition for patients and staff while rural areas remain underserved.

While that level of saturation has not yet reached Pennsylvania, industry professionals and observers are aware of the trend, and anxious to ensure that an appropriate balance is maintained here.

“I think the biggest challenge is that trauma centers in many areas are not established or regulated based on need,” said Dr. Scott B. Armen, who is chief of Hershey Medical Center’s division of trauma, acute care and critical care surgery in addition to serving as medical director of the trauma program.

“There are some areas in Florida, for example, where there are Level 2 trauma centers popping up across the street from one another,” Armen said, “and the reason is not to improve access to care for patients or to improve care for patients, the reason is to increase revenue for the hospital.”

Among the unintended consequences: creating competition for scarce top-level medical professionals, especially surgeons, Armen noted.

“We definitely want to encourage a system to develop such that there are centers close to areas of vulnerability,” Armen added. “But to dilute areas where there is already an adequate resource is not the best thing for the patients.

Regulatory framework

To become a trauma center in Pennsylvania, hospitals must secure accreditation from the Camp Hill-based Pennsylvania Trauma Systems Foundation, or PTSF, as required under a 1985 state law. Initiating the process is voluntary, however — neither the foundation nor government officials decide who applies, so there is no overarching plan requiring trauma center coverage in underserved regions.

The foundation is, however, working to promote trauma center accreditation in rural, underserved areas, including through the use of federal grants that allow PTSF to waive accreditation costs for critical access hospitals pursuing Level IV accreditation.

“Overall we still see gaps, definitely,” said Juliet Altenburg, executive director of the foundation. “It’s just so challenging in the rural areas.”

Recent developments underscore that trend. In addition to Geisinger Holy Spirit, Sept. 1 also brings the accreditation of another Level II center: Wilkes-Barre General Hospital, in the state’s urbanized northeastern corridor. It’s about five miles away from another Level II trauma center, Geisinger Wyoming Valley Medical Center, which is located in a suburb of Wilkes-Barre.

More trauma centers could be coming to the state, but their distribution continues to favor eastern Pennsylvania.

Eleven facilities are seeking PTSF accreditation, a process that can take several years, Altenburg said. Four are in the largely rural central belt, from Dubois in the north to Fulton County in the south, while a fifth is in Williamsport, in northcentral Pennsylvania.

The remaining six are spread across eastern Pennsylvania, with none in the west.

There are consequences to the ongoing imbalance. Preventable death rates due to trauma can be as high as 85 percent in rural areas, according to PTSF. The foundation believes the rate could be decreased throughout the state by the creation of an integrated statewide trauma system that not only promotes trauma center coverage in rural areas but avoids over-proliferation of high level trauma centers in appropriately covered areas, Altenburg added.

Legislating such a framework could be the solution, Altenburg said, and an internal foundation committee is studying the issue. Before PTSF recommends any changes in legislation, however, she said the results of the committee’s findings will be presented to the foundation’s board — something expected to happen this fall — and further consultation with stakeholder agencies, such as The Hospital and Healthsystem Association of Pennsylvania and the Pennsylvania Nurses Association, also will be necessary before the foundation considers making any recommendations to lawmakers.

Life in the field

Amy Spangler

Competition from other facilities is not a primary concern, say key staff at Hershey Medical Center, the state’s only trauma center accredited for Level I adult and pediatric care.

“I don’t think about what’s happening at other hospitals,” said Amy Bollinger, who serves as pediatric trauma program manager.

“I wish them the best,” she said of Holy Spirit, “but we’re here to provide care to patients and families 24/365, and that’s where I’m focused.”

Bollinger, Armen and their colleagues have plenty to keep them focused.

The facility admitted 1,800 trauma patients in 2016 — 600 is the threshold to be considered Level I — and about one-third of the cases were pediatric. Volumes in 2017 are up 9 percent year-to-date, said Michael Lloyd, Hershey’s adult trauma program manager.

Among other criteria, being a trauma center means a facility is always open, and always has an in-house attending surgeon.

“No one ever plans for a trauma to happen.” Lloyd said. “We just don’t know when that next gunshot, that next stabbing, that next child falling off the monkey bars will happen.”

At Hershey, there are eight full-time trauma surgeons who are fellowship-trained in surgical critical care in addition to general surgery, with two or three on duty each day, Armen said. There also is a dedicated team of trauma nurses, as well as surgeons and residents trained in specialty areas including neurotrauma, head and neck injuries, and vascular care.

“Trauma is a team sport, and it requires many different specialties to be involved in the care of the patient,” Armen said.

Recruiting and retaining team members isn’t easy. Armen pointed to a field in which a limited supply of practitioners is being trained every year, and which experiences high burnout rates due to the nature of the work.

“Because we work at night and on weekends and on holidays, when people don’t typically want to be working,” Armen said.

Increased pursuit of those practitioners in competitive markets “has made it very hard to recruit and retain trauma surgeons when the demand is going up artificially,” he said — a pinch likely to be felt more acutely at academic facilities that often pay lower salaries.

“My first love, next to my children, is trauma — trauma patients, trauma care and everything that goes along with it,” Bollinger said. “As a child, my dad was a firefighter and an EMT, and my earliest memories are of my dad rolling out the door to take care of someone who was hurt. So it just sort of became ingrained in who I am as a person.”

“I feel comfortable in saying that nobody involved in trauma at an academic medical center is in it for the money,” she added. “Not one person, with the amount of time, energy, dedication and commitment that it takes to be part of a Level 1 academic trauma center, is in it for the money.”

Shifting regional landscape

With the addition of Geisinger Holy Spirit, there are now four trauma centers in the midstate. The others are Hershey, WellSpan York Hospital and Lancaster General Hospital, which is a Level II facility. It remains to be seen how the new facility will affect patient distribution across the region.

Given its size, experience and expertise, Hershey Medical Center’s coverage area already was fairly broad. In addition to the midstate, the trauma center has treated cases from New York state in the north and Maryland in the south, depending on factors ranging from patient loads at nearby facilities to the choices made by patients and their families, who sometimes specify where they want to go.

The distribution has also been collaborative, Hershey officials said, with their counterparts at facilities such as Lancaster General Hospital, Geisinger Medical Center in Danville and even Baltimore’s Johns Hopkins Hospital referring cases to Hershey as needed.

Officials with Level II Lancaster General Hospital, meanwhile, find their trauma service area more narrowly focused: more than 90 percent of the facility’s estimated 2,300 annual patients come from Lancaster County, the state’s sixth-largest county.

There is, however, another key factor, PTSF’s Altenburg noted: protocols governing the ambulance companies that bring critically injured patients to hospitals, including which facilities take precedence based on factors such as distance and the nature of an injury.

“It’s not based on hospitals saying, ‘come to us,’” Altenburg said. “So based on where a crash happens, you have to guess that some patients who previously would have gone to Hershey will now be going to Geisinger Holy Spirit.”

Geisinger expects that will be the case, and that it will benefit patients as well as first responders.

“The areas west of Geisinger Holy Spirit are very rural, and the next closest trauma center to the west is about 100 miles away,” said trauma operations manager Paige Jordan. “EMS units transporting trauma patients from rural areas west of GHS will be able to return to their first-due response areas more quickly since they will no longer have to bypass GHS to take patients to other trauma centers.”

Hershey officials reiterated that they are not fretting about competition but focused on care.

“We are the cutting edge of trauma care in central Pennsylvania and have been for a long time,” Armen said. “We’ve had great relationships with our partners to the southeast and southwest, with York and Lancaster General, and collaborate very well with both of those centers.”

“We’ll be excited to work with Holy Spirit as well,” he added. “I certainly will be more than willing to help them and collaborate in any way possible.”

What is a trauma center?

Illustration by John Layton

WHAT: A trauma center must have a team of specially trained health care providers who are available around the clock and have expertise in the care of severely injured patients.

WHO: Those providers may include trauma surgeons, neurosurgeons, orthopedic surgeons, cardiac surgeons, radiologists and nurses.

OTHER ELEMENTS: Specialty resources may also include 24-hour availability of a trauma resuscitation area in the emergency department, an operating room, laboratory testing, diagnostic testing, blood bank and pharmacy.

LEVELS:

  • I: Provides multidisciplinary treatment and specialized resources for trauma patients and requires trauma research, a surgical residency program and an annual volume of 600 major trauma patients per year. Both levels I and II can also be categorized as either adult or pediatric trauma centers.
  • II: Provides similar experienced medical services and resources but does not require the research and residency components. Volume requirements are 350 major trauma patients per year.
  • III: These are smaller community hospitals that have services to care for patients with moderate injuries and the ability to stabilize the severe trauma patient in preparation for transport to a higher-level trauma center. They do not require neurosurgical resources.
  • IV: Able to provide initial care and stabiliztion of traumatic injury while arranging transfer to a higher level of trauma care.

SOURCE: Pennsylvania Trauma Systems Foundation

Roger DuPuis
Roger DuPuis covers Cumberland County, health care, transportation, distribution, energy and environment. Have a tip or question for him? Email him at [email protected].

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