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A CRASH COURSE IN POLITICS

Trauma is the kind of injury that can kill you. It's the scene from ER that starts with flying gurneys, lots of blood and a doctor shouting a laundry list of incomprehensible instructions. That's if you're lucky. Because the fictitious hospital in ER is indeed a "trauma center." There is a surgeon present at all times and specialists on call 24 hours a day. What's more, the place is armed with a sophisticated pre-arrival notification system and staffed by specially trained and experienced nurses.

If you don't end up in an E.R. like the one in ER, you could very well end up like Amy Jackson. She's the much publicized small-town homecoming queen who died in 1992 from what some medical experts say were survivable injuries. Amy was airlifted from a small rural hospital in the San Luis Valley to Presbyterian/St. Luke's Medical Center in Denver. But P/SL failed to diagnose her torn aorta, and she died from the untreated injury the following morning. P/SL does have an emergency room, but it isn't a trauma center. Trauma experts noted at the time that a torn aorta is the most common cause of death in traffic accidents--something that experienced trauma personnel look for in cases like Amy's.

A bill now pending in the Colorado state legislature might have saved Amy's life, if it had been law back in 1992. Senate Bill S95-076--which is expected to pass this session--would require all hospitals in the state to participate in a coordinated system for getting severely injured patients to hospitals certified as trauma centers. Getting the right patient to the right hospital at the right time, as advocates like to describe it.

The concept sounds reasonable enough and, now that it's been three years since Amy's death, surely long overdue.

Actually, the legislation was long overdue before Amy's accident. The first bill proposing to form a statewide trauma system was introduced way back in 1987. But because of fierce market competition and turf battles, it has taken Colorado eight years, five bills, three task forces and a plethora of amendments to get even this close. The issue is still so touchy that the parties involved in the process are almost afraid to talk about it, fearing they'll jeopardize the compromise that has been so brutally wrought.

The crux of the problem is the virtual centerpiece of the bill. A statewide trauma network requires hospitals to transfer a certain percentage of their patients--and the insurance dollars that go with them--to other hospitals. In a highly competitive hospital marketplace, this is a far from popular idea. Trauma bill lobbyist Danny Thomlinson admits, "I heard from legislators, who had obviously heard from doctors and hospitals in their communities, that the real concern was that the larger metropolitan hospitals would get all of the trauma victims, and [the other hospitals] didn't want to see potential business lost."

The original impetus behind the legislation was the Colorado Trauma Institute, a private, nonprofit consortium of designated trauma centers that was created in 1983 by the state health department. Charged with developing standards of care for critical trauma patients and working for the ultimate adoption of a statewide trauma system, CTI has for the past twelve years served as Colorado's clearinghouse, registry, quality-control and lobbying center for trauma-care issues. Its board includes such renowned trauma and emergency-medicine experts as Dr. E. Eugene Moore of Denver General Hospital and Dr. Marilyn Gifford of Memorial Hospital in Colorado Springs. It was CTI that first brought a legislative initiative to state senator Dottie Wham in 1987.

Which was just one of the problems some hospitals had with the idea.
"We haven't always been supportive, because previous bills would've put the Colorado Trauma Institute in control of the whole statewide system," says Larry Wall, president of the Colorado Hospital Association, which supports the current version of the bill. "CTI is a private agency and private organization, and...a lot of our members didn't believe in being subject to the Trauma Institute, which they had no control over at all. Rules and regulations fit better within state government than they do in a private agency."

But Pennsylvania has made a private/public partnership work with its trauma system for ten years now. In 1985 a private, nonprofit group called the Pennsylvania Trauma System Foundation was written directly into that state's laws, with clear authority over an accreditation process for all Pennsylvania hospitals that seek to be called trauma centers.

Linda Dodge, executive director of CTI, says CTI tried a number of different approaches to legislation, including models that split responsibilities between the health department's Emergency Medical Systems division and CTI. "Over the years, we met with the Hospital Association to try to arrive at a workable model. Those negotiations were...unfruitful," Dodge says tactfully.  

But Wall is convinced the folks over at CTI were merely protecting their own jobs: "CTI was for previous legislative efforts because [those bills] built a future for them. This year's bill didn't do that."

Another problem the Hospital Association had with previous incarnations of the trauma bill was the mandated use of criteria to determine whether or not a hospital qualified as a trauma center. National standards from the American College of Surgeons have been the baseline for trauma-center designation by CTI for ten years now (and have been used to certify ten hospitals in the state, with certifications pending on eleven more). But the Hospital Association (with 83 member hospitals) feared the criteria would be too stringent for some of its more rural, less well-staffed or less well-equipped hospitals.

Peg O'Keefe, spokeswoman for CHA, puts it this way: "Having the ACS criteria as a baseline makes sense, but adopting it exactly doesn't allow for flexibility. Some latitude is needed to be responsible to particular needs of outlying areas."

But that kind of latitude makes trauma experts uneasy. Dr. E. Eugene Moore, Denver General's premier trauma surgeon and chief of the surgery department, supported an amendment to the current bill that would have ensured that ACS criteria be used. "The state needs outside guidance in developing guidelines for trauma centers," he says. "We don't have the expertise or the ability to develop them on an apolitical basis. Too many hospitals are concerned about being shut down."

The amendment failed.
Larry McNatt, director of the state health department's EMS division, doesn't see that as a major concern. He thinks the criteria for trauma designation that the health department ultimately decides on will probably follow ACS guidelines "for certain levels." (Hospitals are ranked as level 1-4 in terms of their staffing, equipment and expertise in trauma situations.) He, too, thinks the flexibility of using ACS criteria as guidelines as opposed to mandates is necessary, given Colorado's more rural areas.

That flexibility worries CTI's Dodge. "We're ultimately concerned with the patient," she says. "If you relax the criteria [from ACS standards], patient care could suffer."

It also raises the possibility that rural Colorado hospitals will get trauma designations but that the designation won't necessarily mean they're equipped or staffed well enough to handle serious situations like Amy Jackson's.

In addition to the hospitals' battles over the legislation, Colorado Counties Inc.--a nonprofit association of Colorado's county commissioners--also objected to previous versions. Again, the issue came down to money. Originally, the legislation called for funding to come from an existing pool of money: the Highway User Tax Fund and its "Emergency Medical Services Account." It made perfect sense, since more Coloradans die of motor-vehicle-induced injuries than any other traumas. But that didn't sit well with the county governments, who depend on part of that cash for their local ambulance services.

The funding mechanism for the bill was later changed to target the administrative portion of those EMS monies and leave the counties' portion untouched. That was enough of a change for the counties' lobbyist Micki Hackenberger to note, "We have no position on this year's statewide trauma bill."

State senator Dottie Wham, who waged the eight-year effort to pass the legislation, calls the whole experience a "lesson in trust-building." But the long road has not left her unmarked. "It was terribly frustrating," she admits. "There were times I just wished I were king and could make it all happen, but that's not how it works. We had to overcome fears that some hospitals would be swallowed up in the whole system. We had to make everyone a player, to get them all to play."

Kathy Jackson, who, along with her husband, Paul, was an indefatigable voice for a statewide trauma bill since their daughter's death, isn't looking back. "There's a void there that can never really be filled," she says. "All you can do is do what you can to protect the rest of your family and others' kids, too." Since Amy's death, two more of her classmates from Sanford High have died in auto accidents. "We're just a little school," says Kathy Jackson. "What are the odds? All we can do is talk to our neighbors and friends and let them know if they're ever injured and their injuries are severe enough, if they're given the choice, to ask for a trauma center."

A statewide trauma system would mean you wouldn't have to "ask" to be transferred to the appropriate hospital. You simply would be.

The bill that now stands a good chance of being enacted by the legislature apparently doesn't offend the Hospital Association, because it doesn't mention the Colorado Trauma Institute at all. State health officials will be required to adopt rules for the development and implementation of a statewide trauma system, as well as establish a trauma registry (something CTI has not only established but has been building for ten years). It doesn't ruffle the counties' feathers, because their monies remain theirs. And it doesn't require the use of the ACS guidelines for certifying or designating trauma centers. What those guidelines will ultimately entail will be decided by state health officials, after input from two advisory councils--one "trauma" group and one "joint EMS-trauma" group--that will be appointed by the governor.  

Still, Wham and those at CTI are crossing their fingers. Now pending in the House Appropriations Committee, the bill appears to have nothing but clear sailing ahead. But after so many years, no one's ready to declare victory. Too much depends upon it.

"We don't know how many people like Amy have died, waiting for this bill," says Linda Dodge. Dr. Moore echoes her thoughts. "Amy Jackson was the tip of the iceberg," he says. "She was a tragedy, but just the tip of the iceberg.


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