Sunday, July 01, 2001

Beefing up the ER

Bethesda North wants greater trauma center role

By Tim Bonfield
The Cincinnati Enquirer

        Bethesda North Hospital has launched plans to become a full-blown trauma center, which would fill a void in Greater Cincinnati's growing northern suburbs with facilities nearly as sophisticated as University Hospital.

        Currently, severely injured people in Butler, Warren and Clermont counties who need specialized trauma care must be taken nearly to downtown Cincinnati or to Dayton. But a high-level trauma center at Montgomery's Bethesda North would be able to handle car wreck victims along Interstates 275 and 71 as well as people injured by falls, gun shots, and workplace accidents.

[photo] Emergency room staff work on a patient at Bethesda North's ER.
(Steven M. Herppich photos)
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        The project, which would cost several million dollars and take more than a year to complete, would set up expert trauma teams that would be available 24-hours a day.

        Unlike most emergency departments, which can handle a wide range of routine injuries, these teams would be trained to quickly diagnose and treat “multiple-system trauma,” such as a person with head injuries, internal bleeding and compound bone fractures.

        Handling such patients requires having teams of specially trained nurses and technicians and an array of physician specialists including general, orthopedic, cardiac and neurosurgeons — all immediately available to take on a trauma case. The center also must be stocked with special supplies and equipment, from portable X-ray machines to thermal-controlled infusion pumps.

        Launching a trauma center at Bethesda North also will likely require building a rooftop helipad and may require adding operating rooms.

        Fire chiefs who serve populations north of the beltway say this project has been needed for years.

[photo] At Bethesda North's emergency room, Dr. Tim Henke (left) and Dr. Saheed Koury look over a set of X-rays at the nurses station.
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        “This will help us a lot with the severe car wrecks we see on the highways,” said William Jetter, chief of the Sycamore Township Fire Department. “I think we'll see more lives saved.”

The "golden hour'

        In trauma care, minutes matter. Getting the right tests and treatments at the right time can make the difference between life and death or between a good recovery and a lifetime of disability.

        Emergency medical personnel often say there's a “golden hour,” during which severely injured people stand a good chance of survival if they get expert treatment.

        Bethesda North's strategic location near Interstates 275 and 71 make it a prime candidate for highly skilled trauma care for people who have suffered injuries to multiple internal organs or limbs. Bethesda already runs one of the Tristate's busiest emergency departments, treating more than 46,000 people last year.

        “University Hospital is really too far for (trauma patients) from Butler and Warren counties. The growth in the population in these areas has been pretty profound. And this facility is right in the middle of all that,” says Dr. Anthony Borzotta.

        He arrived in Cincinnati three weeks ago from Portland, Ore., to become medical director of trauma services at TriHealth, the hospital group that includes Bethesda North and Good Samaritan hospital.

        For example, it takes about 15 minutes for an ambulance to drive from Bethesda North to University Hospital — even longer during bad traffic. That means it could take a life squad 20 minutes or more to haul a car wreck victim from Sycamore Township to University Hospital. That same patient could be at Bethesda North in about five minutes, Chief Jetter said.

        “That's a big chunk of that golden hour. And getting from Clermont County to University Hospital is an even longer haul. That's a 40- to 45-minute drive,” he said.

Tough task to earn rating

[photo] Maureen Anders, clinical team manager at Bethesda's ER, goes from one job to another at the nurses station. Bethesda wants to upgrade its status as a trauma center.
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        Technically, Bethesda North wants to be designated a Level II trauma center by the American College of Surgeons.

        Obtaining such a designation is no small task.

        It means reassigning emergency department staff and obtaining commitments from specialists to fill out round-the-clock schedules. It means having operating room staff, radiology technicians and respiratory therapists ready to go. It means having a promptly available operating room at all times, rapid access to a CT scanner, portable X-ray gear and other equipment 24 hours a day.

        Bethesda North would become the area's first Level II trauma center, ranked below only University Hospital and Children's Hospital Medical Center in Cincinnati, both Level I centers. The main differences are that University and Children's must meet minimum patient volume standards and must provide extensive teaching and research. Bethesda North would not be required to do so.

        Supporters of the expansion are convinced it can save lives.

        In 1999, Sycamore Township crews were among several squads that responded to a fiery crash on I-275 involving a collision between a truck and a church van. Fifteen people were injured.

        Several victims required helicopter transport to University Hospital and Children's Hospital Medical Center. Ultimately, three children and one adult died from their injuries.

        No one can say that those patients might have lived had Bethesda North been equipped as a Level II trauma center, Chief Jetter said. But there is no question that some victims could have received faster treatment.

    By November 2002, a new Ohio law will require hospitals that treat trauma patients to seek official designation as a trauma center under standards set by the American College of Surgeons.
    Those standards use 160 criteria to outline four basic levels of trauma service.
    Level I: These are the most sophisticated trauma centers and typically are based in urban, academic medical centers. In Greater Cincinnati, only University Hospital and Children's Hospital Medical Center provide Level I trauma care.
    Of the 160 criteria, 156 are considered “essential.” They include treating at least 1,200 patients a year, having a wide range of medical specialists immediately available 24 hours a day, keeping a fully equipped operating room constantly available for trauma cases, and providing extensive teaching and research.
    Level II: These centers must meet 138 of the 160 criteria. Unlike Level I centers, research and teaching is not required. A Level II center also can treat fewer patients per year and must be ready to provide an operating room in “a timely fashion” rather than “immediately.”
    No Cincinnati-area hospital has been designated a Level II center; Bethesda North would be the first. St. Elizabeth South and Middletown Regional have been considering seeking Level II or Level III status
    Level III: These centers must meet 99 of the 160 standards. Such hospitals often provide a wide range of emergency services, but they lack the full range of specialities, especially during night shifts. For example, these hospitals are not required to have neurosurgery, cardiac surgery or microvascular surgery. Nor do they have to have operating room support staff, radiology technicians, respiratory therapists and certain equipment available 24 hours a day.
    No Cincinnati hospital has been officially designated a Level III trauma center. Experts say several larger community hospitals - including Jewish Kenwood, Mercy Fairfield, Mercy Anderson, Good Samaritan, Middletown Regional and St. Elizabeth South - could qualify with minimal effort.
    Level IV: These centers must meet only 43 of the most basic of the 160 standards, such as having sterile surgical tools, X-ray gear, 24-hour lab services and the ability to communicate with emergency vehicles. This level would reflect the capabilities of the smallest, most rural hospitals.
   Source: American College of Surgeons
        “Even five to 10 minutes can make a difference. Now, when we've got somebody entrapped in a vehicle, and it takes a while to get them out, we'll have the opportunity to take them to a closer facility,” Chief Jetter said.

        In Sycamore Township alone, life squads made 1,562 transports to area hospitals last year. That included 164 people injured in motor vehicle accidents, of which 24 involved entrapments, Chief Jetter said.

Thousands die in trauma

        Bethesda's expansion plans have been accelerated in part by a new state law that creates a statewide trauma system. It also requires hospitals to meet a stringent set of national standards before they can be called trauma centers.

        More than 5,000 Ohioans a year die of trauma-related injury, according to the bill's sponsor, state Rep. William Schuck, R-Columbus. He has predicted the law will save 500 to 1,000 lives a year as more critically injured people are taken to certified trauma centers.

        Traditionally, paramedics have rushed severe trauma victims to the nearest hospital, sometimes regardless of the hospital's ability to handle the case.

        But a growing body of medical studies reveals that such patients often fare better by going straight to accredited trauma centers, even if the initial transport takes longer.

        Draft regulations stemming from Ohio's law state that trauma patients will be transported to trauma centers except for certain situations. A nearby, non-trauma center can be used in cases of medical necessity (such as when paramedics fear the victim might not live to reach a distant trauma center), adverse weather conditions, excessive distance or if transport would cause a local EMS shortage. Non-trauma hospitals also can be used if the trauma center is unable to receive the patient, or if the patient or guardian requests transport to a local hospital.

        The law also requires all hospitals to:

        • Establish transfer agreements that spell out when injured patients must be sent to better-equipped trauma centers.

        • Establish guidelines paramedics can use to decide where to take patients.

        • Improve paramedic training, equipment and injury prevention programs.

        At least 29 states already have trauma systems. Since establishing its statewide trauma system in 1987, Oregon has reduced the risk of death from severe trauma injuries by about 35 percent and has eliminated much of the difference in survival rates between rural and urban trauma victims, according to Dr. Donald Trunkey, chairman of surgery at the Oregon Health Sciences University.

        In Ohio, Cleveland's Cuyahoga, Columbus' Franklin and Dayton's Montgomery counties have regional trauma systems. Greater Cincinnati does not, but that is changing.

        In 1999, a coalition of hospitals, fire chiefs and others formed the Tri-State Trauma Coalition to work out the details of a regional trauma system.

        Even competing members of the coalition have voiced support for Bethesda North expanding to a Level II trauma center, coalition board member Dr. James Hurst says, an emergency physician at University Hospital.

        “If you look at the way the population lines up, this is an important piece of the system for our community,” Dr. Hurst says.

Others push for change

        Bethesda North isn't the only area hospital contemplating change to cope with the new state law.

        Several other community hospitals, including Jewish Hospital in Kenwood and members of the Mercy Health System, are considering establishing themselves as Level III trauma centers, which do not have to provide the same range of 24-hour capabilities as a Level II center.

        “We feel like we provide Level III care already,” says Dr. John Davren, chief medical officer at Mercy Health Partners. “The biggest change for us from the state law probably will be just formalizing things we already do informally.”

        At Middletown Regional Hospital, which has begun planning a new hospital campus, officials have expressed interest in becoming a trauma center, but have not decided whether to seek Level II or Level III designation.

        Meanwhile, the coalition is working with St. Elizabeth Medical Center so its hospital in Edgewood, Ky., can serve as part of the region's trauma system. It likely would serve as a Level II or Level III center, even though it would not be regulated by Ohio law, Dr. Hurst says.

        Aside from agreeing that Cincinnati needs only one Level I center for adults, there has been no agreement among coalition members on how many trauma centers the region actually needs.

        “The system has to be inclusive. We want everybody who can step up to the plate to take part in the system,” Dr. Hurst says.

Construction coming

        For Bethesda North, the work has already begun. By September, the hospital expects to have several of the specialists and support staff members working on a rotating 24-hour schedule. Over the months, the hospital will take on more trauma cases as it adds more people, equipment and capabilities.

        Among the most expensive jobs: adding operating rooms, a long-term project that could cost tens of millions of dollars and has not been decided.

        Among the potentially controversial aspects: adding a helipad.

        Helicopters already land occasionally at Bethesda North's campus, on a ground pad near the hospital. However, it would be better for trauma care to have a rooftop helipad that would eliminate the need to transfer patients from the helicopter into an ambulance to get them into the emergency room.

        TriHealth officials say planning for the trauma center is still so new that they have not approached the city of Montgomery about the helipad issue. However, hospital officials say they hope to reduce neighborhood noise concerns by arranging a flight approach that would keep helicopters over high-traffic areas like Montgomery Road instead of flying over houses.

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