SJR 353 directed the Joint Commission on Health Care to study the need for and efficacy of establishing a pre-hospital and inter-hospital triage and transport plan for trauma patients.

Nationally, and in Virginia, trauma is the leading cause of death for persons under age 45. In Virginia, trauma is the fifth leading cause of death for all ages. The average charge per hospital admission for trauma injuries is three times higher than other acute care admissions. Trauma includes blunt trauma (e.g. automobile crashes and falls) and penetrating trauma (e.g. gunshot and knife wounds) injuries.

Many states, including Virginia, have established trauma systems to improve the medical treatment of trauma victims. Trauma centers are specialized hospital units with surgical and medical specialists, laboratory services, and operating and critical care facilities available to treat severe injuries 24 hours a day. Trauma centers form the heart of a trauma system. The American College of Surgeons has developed an extensive list of criteria that hospitals must meet to be designated as a trauma center.

Research has shown that between 20 and 30 percent of trauma deaths are preventable, and that trauma centers lower the mortality and morbidity of trauma patients. Surgical staffing and early surgical care available at trauma centers are the major reasons why trauma centers can reduce mortality and morbidity rates. However, the value of trauma centers is not fully realized unless severely injured patients are "triaged" to these facilities for care. The triage of trauma patients simply means that ". . . the right patient gets to the right facility at the right time."

For a trauma system to be optimally effective, it is critical to utilize a triage system which appropriately differentiates the most critically injured patient who needs the specialized services and resources of a trauma center from those who can be treated appropriately in other acute care facilities. A number of triage guidelines or protocols have been developed by various medical experts to assist in determining which patients are in need of the specialized services available at trauma centers.

In Virginia, the Office of Emergency Medical Services (EMS) within the Department of Health administers the Commonwealth's trauma system. The Office of EMS, the EMS Advisory Board, and the Critical Care Committee administer a Trauma Center Designation Program. Eleven hospitals across the state have been designated as a Level I, Level II, or Level III trauma center. Another component of the Commonwealth's trauma system is the trauma registry. All hospitals with 24-hour emergency departments must submit information on all trauma admissions to the registry.

While Virginia has established a trauma system and a trauma registry, and has designated trauma centers, there are no statewide trauma triage protocols in place to ensure that trauma patients are transported to the most appropriate facility.

To determine whether statewide triage protocols are needed in Virginia, an analysis of 1994 trauma registry data was conducted. In 1994, a total of 25,817 trauma admissions were reported to the registry. On a statewide basis, approximately 51% of the less seriously injured trauma patients were admitted to non-designated hospitals, while the remaining 49% were admitted to trauma centers. Approximately 24% of the more seriously injured trauma patients were not admitted to a trauma center. Of these patients, only 11% eventually were transferred to a trauma center. The vast majority (93%) of the most critically injured trauma patients were admitted to a trauma center.

The analysis of data also indicated that triage practices vary by EMS regions across the state. For instance, the number of more seriously injured patients not transported to a trauma center ranged from 11% in the Tidewater region to 32% in the Federation region and 31% in the Northern and Southwest regions.

In view of the research that indicates trauma centers have better survival rates and outcomes than non-designated hospitals, the more seriously injured patients in Virginia who are not being admitted to trauma centers may be experiencing less than optimal outcomes. Consequently, statewide triage protocols for trauma patients may enhance the effectiveness of Virginia's trauma system.

Four policy options were presented in the draft issue brief for consideration by the Joint Commission.

• Option I would maintain the status quo.

• Option II would introduce a Study Resolution Directing the Office of EMS, in Cooperation with the EMS Advisory Board, the Critical Care Committee, the Regional EMS Councils, and Representatives of the Emergency Medical Services Community to Study Further the Number of Preventable Trauma Deaths in Virginia and Ascertain Whether a Statewide Triage Plan Would Reduce These Preventable Deaths.

• Option III would introduce a Resolution Directing the Office of EMS, in Cooperation with the EMS Advisory Board, the Critical Care Committee, the Regional EMS Councils, the Trauma Centers, the Virginia Hospital Association, the Virginia Chapter of the American College of Emergency Physicians, Representatives of the Emergency Medical Services Community and Pre-Hospital Providers, and Other Appropriate Organizations to Develop a Draft Statewide Pre-Hospital and Inter-Hospital Triage Plan and Present the Draft Plan to the Governor and the Joint Commission on Health Care.

• Option IV would introduce Legislation Requiring the Board of Health to Establish and Implement a Statewide Pre-Hospital and Inter-Hospital Triage Plan.

Our review process on this topic included an initial staff briefing which you will find in the body of this report followed by a public comment period during which time interested parties forwarded written comments to us on the report. In many cases, the public comments, which are provided at the end of this report, provided additional insight into the various topics covered in this study.