Hospitals Want To Team Up For Care Critics Claim Joint Designation For Trauma Treatment Sidesteps Law

Spokane’s two largest hospitals say they can save lives by teaming up to treat the area’s most seriously injured people.

Their unusual plan, however, has some of the nation’s trauma experts shaking their heads in frustration.

At stake are the lives of people who are shot, stabbed, burned, or otherwise severely injured.

Picture this: You’re badly hurt in a car crash and an ambulance whisks you away. Which hospital do you go to? Not necessarily the closest, or your favorite. Instead, paramedics drive to whichever hospital is scheduled to handle that week’s seriously injured.

One week it would be Deaconess Medical Center, the next Sacred Heart Medical Center.

“It’s historic,” said Jim Nania, emergency room director at Deaconess. “It’s really, absolutely exciting.”

The plan is the hospitals’ response to a state law requiring health officials to appoint a limited number of hospitals as trauma centers.

When trauma cases are concentrated among a smaller number of surgeons, the theory goes, they’ll gain more experience and save more lives.

Fewer hospitals will treat the seriously injured, but those that do must meet higher standards of expertise, equipment and education.

Washington is following a national trend to improve treatment for trauma - the No. 1 killer of people under 45. Health officials predict 263 major trauma cases in Eastern Washington this year and 2,284 statewide.

While other hospitals fiercely compete to become trauma centers, Sacred Heart and Deaconess are the first in the state to apply for a joint designation.

Only two major trauma designations will be assigned in the state’s nine eastern counties. The Spokane hospitals expect a decision on their proposal in late February.

Critics say sharing the designation would sidestep the law’s intent.

By using trauma surgeons, assistants and equipment at both hospitals, neither will achieve the desired expertise, said Gerald O. Strauch, director of the American College of Surgeons’ trauma department.

“It’s almost impossible,” Strauch said. “If you diffuse the experience - especially if it’s not a large community to begin with - you’re really depriving patients.”

The hospitals predict that together they would see about 500 trauma patients a year, many of them major. However, the American College of Surgeons recommends at least that many cases for a single trauma center.

Deaconess and Sacred Heart do have the support of state health officials who help select the centers.

At first, the notion of hospitals sharing a designation was “very much opposed,” said Janet Griffith, director of the state Emergency Medical Services and Trauma System.

Not anymore. “I think it’s exciting to see the providers in the community working together to solve a problem,” said Griffith. “We have been more flexible than a lot of states in our rules.”

Besides, trauma workers at Sacred Heart and Deaconess will get training and frequent refresher courses in trauma care, said Michelle Haun-Hood, an assistant vice president at Deaconess.

The hospitals’ plan is unique in many ways. They hope to save money by sharing expensive surgical equipment.

They also want to save on salaries by using private-practice, on-call surgeons rather than trauma surgeons on staff, as many hospitals do.

Eighteen surgeons - 10 at Sacred Heart, eight at Deaconess - have agreed to work a rotating schedule. A few of them specialize in trauma; others have some trauma training and experience.

“If they (the hospitals) had to start paying all the physicians who care for patients in ER, that would really become an issue after awhile,” said Haun-Hood.

While on call, surgeons could see patients in their private practices but couldn’t perform other surgeries. They’d also have to be within 20 minutes of the emergency room.

Doctors would keep a close eye on quality of care by reviewing all cases and comparing outcomes, said Linda Greenberg, emergency room director at Sacred Heart.

“I’ll be flabbergasted if we don’t bust this mortality rate down to below the national level,” said Nania, noting the death rate for Washington trauma patients is about 2 percent higher than the national average.

It’s not the first time the Spokane hospitals have traded competition for collaboration recently. They’ve also joined rehabilitation and emergency helicopter services.

But this is one area in which collaboration doesn’t equal quality, warned Donald Trunkey, past chairman of the American College of Surgeons’ trauma committee. The College of Surgeons is the nation’s largest organization of surgeons.

“That’s going to dilute your expertise,” he said. “You’ve got to stop the strategic arms race between hospitals. Every hospital can’t have every service.”

A surgeon at the Oregon Health Sciences University, Trunkey is called upon to survey hospitals that apply for trauma designation.

He suggested the Spokane proposal is based on politics rather than the community’s needs.

Frank Mitchell, a doctor who chairs the American College of Surgeons committee that gives national verifications to trauma centers, said he’d never approve a twohospital designation.

“It generally indicates a lack of commitment by either hospital,” he said.

Across the country, in Erie, Pa., two hospitals 24 blocks apart have been sharing a trauma designation quite successfully for nearly a decade, say organizers.

“To my knowledge, we’re the only one where the program actually alternates on a daily basis between two hospitals,” said Dennis Evans, who directs Tri-State Trauma System.

Trauma patients alternate between Hamot Medical Center and St. Vincent Health Center, where trauma surgeons are paid to spend 24 hours at a stretch.

“They’re sleeping, eating, drinking in the hospital, three times a month apiece,” said Evans.

Nine surgeons treated 1,700 trauma patients last year - well above the 50 apiece recommended by the College of Surgeons.

“Best of all,” said Evans, “it shares the resources and doesn’t burden either hospital too much.”

Evans said there’s little danger in having surgeons 20 minutes away instead of at the hospital, a change the Erie hospitals are considering. “The only time you might get caught is with penetrating trauma” such as knife and gunshot wounds, he said.

In a community like Spokane, where 9 of 10 cases are blunt trauma, such as car accidents, inhouse surgeons aren’t as critical, Evans said. “It becomes a point of diminishing returns.”

Pennsylvania health officials had “major heartburn” about the joint program at first, but finally accepted it, he said.

In Spokane, paramedics who transport trauma victims would be among the first to notice the change. “In the past, flow to a hospital has been based on patient preference and closeness,” said Dave Byrnes, chairman of the East Regional EMS Council.

Distance shouldn’t be much of a problem since the hospitals are several blocks apart, he said.

The Spokane hospitals are still ironing out some details of their proposal. For instance, what about patients with insurance covering only one hospital? What happens when a patient’s personal doctor wants to come to the emergency room but has privileges only at the other hospital?

And an important issue for paramedics: What happens when the patient insists on going to a different hospital?

“I don’t want to see a poor paramedic out in the field getting stuck with this,” said Byrnes.

A current state law that gives coherent patients a choice in hospitals should solve that problem.

“Maybe if they’re really adamant, they’ll be stabilized and transported,” said Greenberg. “We’re not usually into kidnapping.”