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Legacy of the Illinois Trauma and Emergency Medical Services System (EMSS) Program, Circa 1971-75
David R. Boyd MDCM, FACS and Teresa L Romano RN, MBA
In March 1971 the Illinois Medical Journal (IMJ) published, “The critically injured patient: A plan for the organization of a statewide system of trauma facilities”. (1) This paper described Governor Richard B Ogilvie’s plan to improve trauma care based on practices of the Trauma Unit at the Cook County Hospital (CCHTU) in Chicago by developing Trauma Centers within a regionalized Emergency Medical Services System (Trauma/EMSS). (2) This novel approach would join many new and previously isolated elements into an effective “System”. The trauma program concept was built on surgical principles andregionalizing trauma care and effected a constellation of other processes including; , identifying new professional roles, massive training and education, selective specialty designations and emergency categorization of hospitals, upgrading and coordinating of pre-hospital components, creating new methods for data collection, clinical research and cost controls through consolidation of limited critical resources.(3, 4, 5)
Ogilvie created the first public health initiative to improve trauma care delivery. This new paradigm involved practicing physicians, hospitals and public safety organizations in a coordinated effort. He established the first Trauma/EMSS “Lead Agency” (LA) within the Illinois Department of Public Health (IDPH) to plan, develop and coordinate the overall program. The Illinois Medical Journal (IMJ) published the initial and many subsequent reports and was a prime source for professional information on the Trauma Program. (1, 6,7,8,9,10,11,12, 13, 14, 15, 16, 1718)
This report is a 40 year reflection on the formative period and a brief description of the Illinois impact on national Trauma/EMSS policy, programs and legislation. The Illinois emphasis on clinical and public health principles, critical program elements, operational components and implementation strategies were directly integrated within subsequent federalEMSS laws, regulations, program guidelines, technical assistance and grant funding. (19, 20, 21, 22, 23) The Illinois Trauma/EMSS program had a direct impact on untold numbers of communities and states as well as foreign countries. (24, 25, 26, 27, 28, 29, 30)
The Originating Conceptual Framework:
Drs. Robert J Freeark and Robert J Baker established the first civilian Trauma Unit (TU) at the Cook County Hospital (CCH) in March of 1966. ( 31,32) Dr. David R Boyd, a general surgery and TU chief resident, emphasized new teaching and critical care practices, staff training, protocol development and clinical research. He described the specific identity of a TU within the hospital organization and the authoritative role of the trauma service medical director. He saw the need to progress from a “Unit” to a larger Trauma Center (TC) concept to promote excellence in patient care, professional education, applied research, data management and a variety of “outreach” practices. He became a popular speaker with Chicago surgical, hospital, health and governmental groups and received a civic award. (33) This recognition caused a series of rapidly occurring and connected events which significantly changed the future direction of trauma care in Chicago, the State of Illinois and elsewhere.
Governor Richard B Ogilvie, former Cook County Board President (1962-68), took notice and interviewed Boyd, who recommended that an organized system of trauma centers be established statewide, “so that lives could be saved as was routine at the CCHTU”. Ogilvie asked for a “Statewide Trauma Center Plan”. Boyd and Dr. Bruce Flashner, a former CCH general surgery resident then with the Illinois Comprehensive Health Planning Agency (CHP), wrote a plan based on their clinical and organizational experiences on the CCHTU. (1, 3) Their approach was to categorize all hospitals and to specifically designate some 40 trauma centers in a “Three Echelon TC System” (i.e.; Regional, Areawide and Local) in the nine administrative state regions. These selected and designated hospitals would incorporate CCHTU concepts and practices. In Chicago several specialty centers would be designated for major burns, spinal cord injuries and pediatric trauma. (34, 35, 36, 37, 38, 39, 40, 41, 42) Later on, special categories for cardiac and high risk infants and ancillary programs such as organ retrieval were added. (43) There would also be a complementary prehospital Emergency Medical Services (EMS) System including both ground and air ambulance transportation. (44, 45, 46) The initial program funding for the basic Trauma/EMSS came from the1966 National Highway Safety Program: Standard 11 that established goals for improving “road safety” by providing to states and units of local government matching funds for ambulances, communications and Emergency Medical Technician (EMT) training. (47)The expansion toward Advanced Life Support (ALS) services and other clinical modalities was facilitated by a White House- Department of Health, Education and Welfare (DHEW) EMSS Demonstration Contract. (48, 11) Ongoing after grant support was maintained through legislated general funds. These experiences influenced federal EMSS legislation and the administration of the DHEW and later Department of Health and Human Services (DHHS)grants program. (19,20,21, 22, 23)
Lead Agency Concept:
Ogilvie appointed Boyd as Director of Emergency Medical Services and Highway Safety in the IDPH and assured that the Trauma/EMSS program would maintain a clinical trauma surgical focus and the home office would be at the CCHTU. Over the next 4 years (1971-75), Boyd, Robert J Lowe and Teresa Romano in their dual capacities as surgeons and staff nurse on the CCHTU and in the IDPH conceptualized, described, demonstrated and taught trauma care, trauma unit organization, trauma systems integration and developed many of the EMSS operational components recognized today. These two trauma programs, juxta-positioned on the third floor of the CCH, complementary in function, became the “Menlo Park” (49)of Trauma/EMSS development. Hundreds of interested physicians, surgeons, nurses, healthcare professionals and their foreign counterparts visited and took away concepts and program materials from this conjoined program.
An ancillary administrativeoffice was maintained in Springfield for essential intra- and inter-governmental functions. It was soon clear that a myriad of governmental functions would impact the trauma delivery system including; professional and the new para-professional certifications, hospital licensure, public safety, law enforcement, communications, Civil Defense and disaster preparedness, to name a few. Getting interagency consensus, support and cooperation was a novel and challenging experience. A new government entity, the Trauma/EMSS “Lead Agency” (LA) was established in IDPH. The LA would have “primacy” on all state governmental matters relating to Trauma/EMSS, facilitating inter-agency cooperation and consistency. This bureaucratic maneuver was dramatic and critical to the success of the program. By definition, the LA is the organizational and operational unit with overall Trauma/EMSS responsibility. The many potentially obstructing sister agencies were brought together for collaboration and keptthe mission focused by the LA. The Illinois LA organization and operation was copied and implemented in untold number of communities, states and foreign countries and was integrated into the subsequent federal legislation and national Trauma/EMSS program. (1974-83).
In 1972 Boyd lobbied for replication of this Lead Agency concept during Congressional testimony for the pending EMSS legislation.(19,20) The Department of Health, Education and Welfare (DHEW) under “section 1208”, designated the Division of EMSS (DEMSS) as the “Lead Agency” within the federal government with the responsibility fordevelopment ofthe national program, to coordinate and maintain consistency of all federal activities relating to EMSS.
Section 1208:“The Secretary shall administer the program of grants and contracts by this title through an identifiable administrative unit within the DHEW.’
The strategic goal of the DEMSS was to establish a “Lead Agency” for Trauma/EMSS in health departments in every state, major city and the large populated counties and to develop a program of 304 contiguous ”Wall to Wall” Trauma/EMSS regions(50) utilizing the “Systems Approach”. (51, 52, 53) The tactical plan was to replicate proven clinical models for trauma, cardiac, poison control and other clinical entities within each regional system and to build capacity for all of the 15 congressionally mandated operating components (e.g.; training, transportation, communications, facilities and critical care units, etc.). (19, 20).These components were considered supportive infrastructure to the clinical systems and flexibly funded as implementation required. The new programs were lead by competent and charismatic clinicians who provided irreplaceable learning experiences that influenced further professional interest and acceptance.
Regional Trauma Systems:
The Trauma/EMSS regionalization of today was not feasible prior to the 1960’s. Bio-medical research in specialized units on the pathophysiology of hemorrhagic shock and cardiac arrest evolved new approaches for trauma patient resuscitation and stabilization. Using the Systems Approach, methods were devised to enable these time critical interventions out of hospital and in designated general hospitals. (54, 55) The “system” was modeled from previous military experiences of rapid response; field stabilization and direct triage transport to a designated TC, importantly, by-passing other less capable community hospitals. It was asserted that the Trauma/EMSS would improve injury survival outcomes. Most everyone statewide accepted that premise.
The initial question for Illinois in 1971 that focused the LA was: “Could the experiences of a busy urban trauma center, expert in injuries produced by acts of violence and managed by a full time resident surgical staff be transferred to the downstate community hospital with a low frequency of trauma cases caused primarily by motor vehicular accidents that produced multiple and CNS injuries to be cared for by independent practicing surgeons?” In most downstate metropolitan communities there were enough surgeons, specialists and support personnel within the community but not enough to staff several trauma centers, improve efficiency and clinical outcomes or meet later established national trauma standards. These surgeons were represented in small group practices, “on call” to several hospitals and with varying trauma training and experience. Individual negotiation with these surgical groups led to the establishment of a combined “Trauma Call Roster”. General and specialty surgeons responded to a 24 hour trauma call for seriously injured patients admitted to their designated TraumaCenter. Consolidating these surgical resources on one team brought an “epiphany” similar to that of the CCH TU surgeons in 1966. It was obviously better for patients, surgeons and hospitals. (1, 31, 32, 36) There was no looking back.
The selective Trauma Center Designation was a radical departure and required the good will of many. Hospital administrations across the state had mixed opinions and considerable anxiety over this key program requirement. The singular public designation of a central receiving trauma center was the conceptual raison d’être, the crucial threshold issue and the key to the success of the plan. The Illinois Hospital Association (IHA) led by their farsighted Executive Director David M Kinzer was publicly supportive and critically important to the hospital membership’s acceptance of the plan. Trauma center designations in Chicago were accomplished by direct negotiation with University Hospitals that had surgery training programs. These new Regional TC’s provided high level trauma care and an optimal geographic distribution. Downstate the Regional and Areawide TC designations were accomplished by a variety of open local “EMSS Council” determinations. The Local TC’s were designated in small hospitals providing access for a 30-50 mile radius, and from there a similar distance to an advanced TC. (1, 15,16, 17) Once the hospital designations were decided, the CCHTU organization and practices were appropriately modified and successfully installed in the three levels of trauma center care. Theimplementation of the prehospital EMS System was developed as an extension of the trauma center network in each region. From a moderately traumatic birth the Illinois Trauma/EMSS rapidly developed, gained momentum, expanded into new clinical areas, described new approaches and provided a wealth of new health care delivery concepts and learning experiences. Some of the key features are described below.
Socio-Geographic Regional Models
Every utility definition of region implies space and place. Trauma/EMSS regions are, in addition, described by size, shape, population density and hierarchal treatment capacity. Regionalization of EMSS includes a process of identifying clinically specific medical emergencies, responding with appropriate treatment according to protocol and selectively transporting the most seriously ill or injured patients to a designated facility that can provide definitive patient care in the shortest time within a defined geographic area. Each Trauma/EMSS region is uniquely described by the availability and arrangement of the fixed hospital and designated TC resources. (54, 55) Trauma regionalization in Illinois was deployed in the nine preexisting government administrative regions. (1,3,4, 15) In 1972 these were sub-divided into 28 area groupings for better medical control and supervision of the Advanced Life Support (ALS) Cardiac program. (56, 57, 58 ) Later using the Illinois regionalization “template”, a national EMSS map of 304 contiguous Trauma/EMSS regions was developed. (50) Further experience and study in critical resource availability lead to the description of three “Socio-Geographic” regional models (i.e.; Urban-Suburban, Rural Metropolitan and Wilderness-Metropolitan). Soon every person at home or away was within a federal-state recognized EMSS region. Eventually by 1975 there would be 20 Urban-Suburban (6 %), 206 Rural-Metropolitan (68%) and 78 Rural-Wilderness regions. (26%) By design and need, the per capita federal grant funding for rural systems was four times higher than urban systems. (51)
Urban-Suburban Regions, Model X
Chicago with the surrounding sub-regional suburban counties was the model for EMSS program development in similar communities. Medical sophistication and affluence of operational components was not enough to establish an effective operating system. Cooperation, oversight and some discipline was essential and elusive. The LA engaged as a referee with coordinating responsibility for the difficult component issues (e.g., hospital emergency categorization and specialty care designation) and multi- jurisdictional debates. Pre-Hospital EMS was typically provide by the municipal Fire Departments and occasionally by a separate EMSS “Third Service Agency”
Rural-Metropolitan Regions, Model Y
The classic mid-America region was demonstrated in Champaign-Urbana, Peoria, Rockford and Springfield and their several aligned counties. The trauma regionalization plan was similar to other economic and marketing arrangements and was readily accepted. The clinical rationale and cost control through consolidation of critical care resources had intellectual appeal. However, making the selective choices between the large community-invested hospitals was a major challenge. The selective TC designation and consolidating optimal care capacity into one 24/7 Trauma Center won the day and is a tribute to the community ethic displayed over and over again in the mid-America heartland. Pre-Hospital EMS was more variably provided by; Fire departments, occasional by the Police and successful private “contracted” EMS companies. In the more rural areas volunteer EMS was most common.
Wilderness-Metropolitan Regions, Model Y’
Southern Illinois as in Carbondale, Mount Vernon, Harrisburg and Cairo became the regionalization model for the western High Plains, Intermountain Desert, Alaska and Indian Country (59) and demonstrated the potential for further extension of the rural model to remote ultra-rural areas. The immutable geography, distance, weather and limited care resources form a pre-set of difficult issues. These many factors bring unique problems that are not only difficult and costly to fix but also hard to maintain. The perpetual problems of injured patient identification, long transport distance to specialized care, low utilization of EMSS components and professional isolation are intertwined and complicated. Maintaining sparse local resources with infrequent demand have opportunity costs, as do mobilizing these for expensive transports. The lack of consistent inter-professional communication contributes to EMSS dysfunctions. Maintaining professional linkages to small outlying hospitals and EMSS programs with their distant “TraumaCenter” and an effective “System” is a daunting challenge. Telemedicine and other technologic outreach concepts can be effective once the professional connections are established. These ultra-rural systems remain perpetually fragile and require continual maintenance and support.Pre-Hospital EMS was based predominantly on volunteers, Creative use of the remote industry, i.e., logging and mining operation’s plant safety equipment and personnel helped in providing coverage. This remains a most intractable EMSS deficiency.
The trauma systems model is unique in that improved care can be realized and will show wide spread regional impact by organizing existing resources prior to implementation of any othercomponent enhancements. (4,60 ) Rural trauma systems are built and maintained with Basic Life Support (BLS) elements primarily with Emergency Medical Technicians (EMT) and triage protocols to a designated trauma center. The consistent use of the pre-planned inter-hospital “Transfer Agreements” decreases confusion and lost time and remains the critical factor in improved trauma patient outcomes. (20, 21, 22) Other medical conditions were grafted onto the basic trauma regionalization scheme. Complementary systems analogues of general trauma including burns (42), spinal cord injuries (38,39) pediatric trauma, (38) cardiac care, high risk infants, poisonings, organ retrieval and transplantation, limb reimplantation, radiation injuries, psychiatric and behavioral emergencies followed.(51, 52, 53) The prehospital cardiac concept was imported to the USA from North Ireland. Pantridge a cardiologist in Belfast in1966 (61) noted that most acute cardiac deaths occurred at home and developed the first rapid responding pre- hospital cardiac program. This was modeled in the USA by Lambrew (62) in New York and Cobb in Seattle (63). In 1972 Dr. Stanley Zydlo, an Emergency Physician from Arlington Heights developed the first Advanced Life Support (ALS) paramedic program in several northwestern Chicago communities. Recognizing the enormous growth potential for these ALS programs prompted the IDPH LA to obtain public health legislation and oversight responsibility to insure patient safety and program consistency.(56) The concept of “Medical Control and Accountability” for prehospital ALS introduced new terms of “Off-Line” and “Online” medical control and “Operational” and “Treatment” protocols. (56, 57, 58) The Illinois legislation, regulations and experience became part of the federal EMSS technical assistance and a requirement for all ALS grant programs. The rapid national expansion of the paramedic ALS programs was stimulated by the popular TV show “Emergency” in the 1980’s.