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In the quest for regionalization of emergency care, the U.S. trauma system is typically regarded as the model of success. Hospitals are classified by their resources, injured patients are taken to the level of care best suited to help them, and the system basically fulfills the idea of the "right patient to the right care at the right time."
Why shouldn't such an approach work, one might wonder, across a range of specialty care—strokes, burns, poisonings and more? And here's a logical next thought: Wouldn't it make sense to combine the numerous resources required for such various areas of specialty care under one easily accessible roof?
That's an idea touted by Philadelphia Fire Department medical director Crawford Mechem, MD, who describes such centrification as a care-enhancing cousin to regionalization.
"The idea is that as prehospital care becomes increasingly sophisticated," Mechem says, "it may become appropriate for EMS systems to identify, within their own receiving hospital groups, hospitals that are able to continue high-level care initiated in the prehospital setting."
Consider the idea of hypothermia for resuscitated cardiac arrest patients. If prehospital services begin cooling such patients—and more are every day—what happens when they arrive at a hospital that doesn't?
"As that practice gains ground around the country, and the evidence to support it becomes stronger, some EMS systems may end up administering a level of care higher than that received in their emergency departments," Mechem notes. "If they get to a hospital that doesn't continue that practice, the ball is dropped, and whatever benefit EMS may have initiated may be lost."
That's the idea behind designating cardiac resuscitation centers, but it applies beyond that. In general, resuscitation is time- and resource-intensive, and it takes a certain commitment to do it right and well. Emergency departments without those resources can't provide optimal care for patients who need them, and other patients may suffer if they try.
There are, of course, "resuscitation centers" out there, but they're mostly academic facilities within teaching hospitals that do research and clinical work. They're typically not integrated parts of EMS systems appointed to receive certain patients.
Developing such facilities, Mechem suggests, might start with the existing foundation of trauma centers.
"The precedent is there, it's a nationwide certification process, and it's all well-standardized," he says. "There is evidence to support that trauma systems save lives: They decrease mortality, and they seem to decrease morbidity. The evidence is less for the other specialty centers we recognize, but there's certainly a push in that direction in many EMS systems."
Major teaching hospitals might also be candidates, or even smaller community hospitals willing to invest to grow their capabilities, business and prestige.
Such one-stop specialty centers would not come without issues, of course. One is credentialing. The American College of Surgeons provides a comprehensive, standardized, authoritative process to evaluate and designate trauma centers, but other areas of specialty care aren't as developed. Many lack national bodies with a capacity to do that (though JCAHO credentials areas like critical-access hospitals and behavioral healthcare).
That kind of foundation is necessary before such an idea could move forward. And even with a credentialing system in place, the process of drafting requirements and identifying and transporting to certain hospitals—and, on the flip side, bypassing others—is fraught with peril.
"Bypassing hospitals is always a concern," says Mechem, also an associate professor of Emergency Medicine at the Hospital of the University of Pennsylvania. "Hospitals are businesses, with reputations to keep and bottom lines to consider. Being bypassed can be a black eye. It can affect them financially, and if it's part of a larger trend, it can put an emergency department in real jeopardy. And then you have to think about the impact on the local population."
For each group of patients, it must also be determined if and when specialty-center benefits, assuming they can be demonstrated, would start to diminish with time and distance. Ten minutes of extra transport might be deleterious to a patient in a way that three isn't.
All of that, however, might not matter if such centers can be shown to keep more patients alive and functional in society. After all, the benefits of trauma centers are felt to be worth their costs.
Questions like this, however, remain several years off. For now, we're still pushing forward with research to determine if the types of treatments specialty centers might provide really would make a difference.
"Folks here at Penn and at a lot of other teaching hospitals around the country are working to push forward a whole bunch of both basic and clinical research," says Mechem. "The best way to help them with that is, I think, to bring them the patients, and hopefully we can determine if these interventions might actually help."