A medical group that inspects the hospitals that treat the most severely injured patients has reaccredited only one of the District's six trauma centers and has told the rest they'll have to cure a wide range of deficiencies to win approval.
MedStar at Washington Hospital Center, the region's largest hospital, was "verified" as a Level One trauma center during recent confidential inspections of District hospitals by the American College of Surgeons.
D.C. General Hospital, Children's Hospital, George Washington University Hospital, Georgetown University Hospital and Howard University Hospital now are scrambling to fix their programs and prepare for reconsideration in the coming months.
The rigorous inspections are voluntary and are paid for by the hospitals. But D.C. health officials consider the findings when designating which facilities should receive seriously injured persons transported by D.C. ambulances. Any trauma center without its city designation would soon have too few patients to cover the expense of maintaining its Level One status.
"The hospital which passed has more firepower in terms of caring for the injured than the hospital that didn't," said Gerald O. Strauch, director of the American College of Surgeons trauma department. "We're talking about organization, staff and commitment."
The only other Level One trauma center in the region, Inova Fairfax Hospital, was verified without deficiencies last summer.
Level One trauma centers are specialized units staffed round-the-clock with surgeons and support staff trained to rapidly treat patients injured by gunfire, stabbings, car crashes, falls, fires or blunt force. Only about 15 percent of injured people need such care, experts say.
Level Two or Level Three facilities are qualified to treat major traumas, but they are not required to maintain 24-hour in-house trauma surgery teams.
City officials made it plain yesterday that they expect all District trauma services--which were last verified six years ago--to succeed in renewing their accreditation and that in some cases, the obstacles are minor.
The accreditation issue arises as Mayor Anthony A. Williams (D) leads an effort to restructure the city's health system.
"We don't have an indication at this point that those trauma centers cannot handle their mission and we should rush in and take some preliminary reports and disrupt what is currently an effective system of care," said Ivan C.A. Walks, director of the District Public Health Department. "If the final reports show that only one out of six can get it done, then we have a serious issue."
The unverified D.C. trauma centers (except for Howard, which did not respond to an inquiry) all said they are working to repair their respective deficiencies. The inspectors' criticisms relate to treatment protocols, medical record-keeping, data-gathering for research, specialty training of staff doctors and degree of supervision provided to trainees.
The hospitals characterized the deficiencies as unrelated to direct patient care and said they are confident they can resolve them.
But trauma care experts said that the results cannot be dismissed as bureaucratic nitpicking--especially given that the American College of Surgeons gives trauma centers ample notice and substantial pre-inspection coaching.
"That survey should certainly be a wake-up call," said Gregory S. Bishop, president of an Irvine, Calif., consulting firm devoted to trauma centers. "It focuses attention on a very weak and perhaps unstable public service that people do count on. . . . These are not little rules. They all indicate weaknesses in the infrastructure."
Trauma centers bring prestige to hospitals, but they are very expensive to operate. Even the most successful lose money.
A growing number of private and government health experts say the District has far more trauma centers than a city of its size needs. But those who suggest that the District consider designating only Children's Hospital plus one or two other facilities as Level One trauma centers are in for a challenge.
"Unfortunately, it's politically difficult for hospitals to accept a designation as Level Two because it just sounds like it's not as good, but there's nothing wrong with it," said Samir Fakhry, trauma chief at Inova Fairfax and chairman of the American College of Surgeons regional trauma panel. "The hospital administrators and the physicians would feel that does not reflect positively on them. The reality is that not every hospital can be the best at everything."
The busiest District trauma center is quasi-public D.C. General, which had 1,538 cases last year.
One key difference between MedStar and D.C. General is that the vast majority of trauma cases at D.C. General involve patients without insurance, while a much higher proportion of MedStar patients have coverage. Experts say it is no coincidence that Washington Hospital Center has the strongest finances in the city and the other trauma centers have had money problems in recent years.
The biggest Level One trauma center in the region is Inova Fairfax, the only trauma center in Northern Virginia, which expects 2,000 cases this year.
Connie J. Potter, a former Oregon chief trauma manager who works with Bishop, said District hospitals that want to stay in the trauma business will have to dig into their pockets--or risk having only the strongest survive. "They need to commit the resources to be a player," she said. "It's not something you want to do halfheartedly or haphazardly. It means too much to the patient."