State of shock Challenge: Shock Trauma has seen its beds emptied by pressures from HMOs and other managed care insurers. Now, it is seeking ways to get more patients -- in a field where traditional lessons about attracting patients don't apply.

March 16, 1997|By M. William Salganik | M. William Salganik,SUN STAFF

The Maryland Shock Trauma Center can't get more trauma patients with billboards or bus signs.

Yet without more patients, says director John W. Ashworth III, the pioneering center, which closed 20 beds and cut 66 jobs last fall, would be forced to shrink again in the next few years.

So Ashworth is quietly laying the groundwork to get a larger share of the state's trauma patients. But Shock Trauma's gain would come at the expense of other trauma centers, at a time when Maryland hospitals - with 40 percent of beds empty - are competing fiercely.

Other trauma centers in the state say they can care well for the patients they get.

Like all hospitals, Shock Trauma has seen its beds emptied by pressures from HMOs and other dollar-conscious managed care insurers, which have pressed to make hospital stays shorter.

Over the last decade, the average length of stay at Shock Trauma has dropped from 17 days to 5] - and is expected to drop to four within five years. The result is that, although the number of patients has remained steady, revenue has been dropping and profits are razor-thin.

It's a trend, officials say, that can't continue if Shock Trauma is to retain its pre-eminence.

"The greatest trauma center in the world is going to stay the greatest trauma center in the world because we anticipated," Ashworth says. "I don't want to be sitting here and have an HMO tell me, 'We're going to do all we can to make sure patients don't come to Shock Trauma.' "

So far, the potential fight over patients hasn't surfaced as an issue. Ashworth has been quietly working to change the criteria under which emergency medical personnel decide which injured patients need to go to a trauma center and which center would be best for them.

His goal is to get the number of patients admitted to Shock Trauma, part of the University of Maryland Medical System, up from 5,376 in the fiscal year ended June 30,1996, to about 6,000 by 2000.

"This is a center that this state and this university have put here for the citizens of Maryland," Ashworth says. "With the extraordinary resource and the capacity we have, we should be using this resource to its maximum extent."

The state's emergency medical board, reorganized under 1993 legislation as a state agency separate from the Shock Trauma Center, is completing regulations for trauma care and recertifying the state's nine trauma centers, a process expected to take about 18 months.

While that might seem like an opportunity to rewrite the rules to shift patients, Dr. Robert R. Bass, director of that agency, the Maryland Institute for Emergency Medical Services Systems (MIEMSS), says he doesn't expect dramatic changes in where patients go.

But Ashworth says over the next few years, both through changes in emergency medical protocols and from "educating" other hospitals that more patients should be referred to Shock Trauma, he believes he can increase admissions to keep most of his 72 beds filled.

New technology

Some of the shorter stays that have emptied beds are the result of new technology. "Five years ago, for internal injuries, when I saw a little blood, I was obligated to go inside and look around. Now we have CAT scans," allowing quicker evaluation and treatment, says Dr. Andrew Burgess, chief of orthopedic surgery at Shock Trauma since 1982.

Some, reflecting insurance pressure, result from moving patients lower-cost rehabilitation facilities as soon as possible. Last year, 18 percent of Shock Trauma's patients were discharged to rehabilitation or skilled nursing facilities or sent home with the support of home health services.

"Financially, we're slitting our own throat," says Dr. Richard Dutton, physician director of quality management at Shock Trauma. "We get patients out the door quicker, we lose money."

Shock Trauma's scramble for patients is aimed at preserving the center that the late Dr. R Adams Cowley charmed and bullied into being two decades ago.

A national pioneer in trauma medicine, Cowley preached the importance of treating severely injured patients as soon as possible -- within the "golden hour." This means trained emergency medical technicians, quick transport and centers in hospitals with trauma specialists at the ready.

Trauma network

In the late 1970s and early 1980s, Maryland built one of the country's first and most complete trauma systems, with the Shock Trauma Center at its core.

Eight other trauma centers were set up. They provide geographic coverage from Cumberland to Salisbury to assure quick treatment of patients hurt almost anywhere in the state.

And several of the centers have specialties: Johns Hopkins for pediatric trauma and its Wilmer Eye Institute for eye injuries, Johns Hopkins' Bayview Center for burns.

A fleet of helicopters, operated by the state police and monitored on giant screens at a MIEMSS command post on the University of Maryland at Baltimore campus, rushes the injured to treatment.

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