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Monday, November 12, 2012

Implications of Health Care Reforms on U.S. Trauma System

Up close and personal with the U.S. Health Care Trauma System
October 16, 5:17 P.M. I received the call, “Your son has been hit by a car. “At this point everything slowed down inside my head and all noise from the outside world was muffled. First, I breathe and then ask, is he conscious? Thankfully, he was alert according to the paramedic on the scene. He was being transferred to the local hospital emergency room for further treatment. By this time it is too late to make it down to the 5:30 ferry, so I was relegated to the 6:45, which means I wasn’t on the beach to see my son until 7:45P.M. I gave the paramedic my information and called the hospital giving them my E.T.A.
Traumatic Brain Injury
8:00 P.M. I arrive at the local hospital, a 262 bed facility with a Level III Trauma Center, and immediately found my teenager in the E.R. The treating physician informed me that he had multiple fractures, on his head and leg, the most worrisome of which was the skull fracture. (My son had just bought his new skateboard and did not have his helmet at the time of the accident.) The first thing Nathan says when he sees me is “I’m sorry Mom,” and then he starts asking for pain medication, yet he was calm, and composed. The doctor informs me the head trauma has caused a brain bleed, and Nathan needs to be transferred to a pediatric trauma center. At this point, I requested Seattle Children’s Hospital for the transfer, but it turned out that Harborview Medical Center had the pediatric –neuro-rotation for that night.  So off we went in the ambulance to the Level I Trauma Center, which is funded by the State through the University of Washington.
If you haven’t experienced the controlled chaos of an urban trauma center, it is reminiscent of a mental health ward, serves as a repository for the homeless in varying degrees of inebriated battle-weary skirmishes, and of course, is the collecting point for trauma victims. Some patients were on gurneys in the hallway while more urgent cases were treated in the E.R. suites, which were divided only by a curtain which runs two feet above the ground, and circles the bed like a shower curtain. Consequently you can hear everything in the ward, which can be somewhat disturbing.
Patient Safety Observations
Nathan was admitted to Harborview at 11:10P.M. October 16th. Throughout the night teams of specialists came in to examine him and he was not allowed to sleep until he could be fully evaluated, after the C.T. scan(s). Teams included pediatric neurological surgeons, general care pediatricians, orthopedic surgeons, and ortho/maxillofacial  surgeons.  Procedures which he endured included putting a cast on his leg and a second cast on his arm, which was later removed after it was discovered there was no arm fracture, and lots of tests. Unfortunately whoever installed the I.V. line did not removed the tourniquet after finding a vein and it was allowed to linger on his arm until the next day. This included some nurse actually attempting to put a blood pressure cuff over the tourniquet, which was high up on his arm and slipped under the cap sleeved gown. The tension of the tourniquet left a circular barbed-wire-tattoo on his arm. If he had circulatory problems this safety lapse may have caused severe problems. During his hospital stay, the phlebotomist came in to draw blood and asked if he was the patient in Bed A or Bed B, and I said I don’t know what bed this is, but he is my son and his name is Nathan. Again, isn’t it a better verification to use a patient’s name rather than the bed insignia?
Shortage of Beds for Patients
October 17, 5:30A.M. Nathan was transferred to the Intensive Care Unit where he spent two days for observation of his brain bleed, which had doubled in size but was stabilized. Yes, we spent the night in the E.R., with him on the gurney and me in a straight-backed chair, because we were waiting for a bed to become available anywhere in the hospital. This is not an unusual phenomenon for urban trauma centers, as they received referrals from all regional hospitals, for Traumatic Brain Injury (TBI) cases, burns, and other traumas. Children of course get top priority, so a bed was found. Literally, this trauma center does not have enough beds for its patients.  The Intensive Care Unit (I.C.U.) floor featured a shared ward with the burn victims and as it turns out, one mental health patient in the midst of an episode. Though the room was private and it actually had views of the harbor, the hallway between all of the other “rooms” in the ward was an open design, separated from the patient’s area only by a curtain. This meant that sound carried throughout the ward. Thankfully Nathan was loaded up on some pain medication and I crashed out on one of those folding bed/chairs.
Who Pays the Bill?
At both the local hospital and the regional trauma center, I was queried on where I worked, if I had full-time or part-time employment, and other insurance payment questions. Incidentally, evidence of employment in the United States does not mean that medical insurance is available to the employee or her family, as only about half of all businesses offer any type of group medical insurance. This payment interrogation is part of the follow-the-money-trail of all health care providers in the United States. Even though my son had insurance and I presented his insurance card, there is still the secondary payer inquiry, to allocate fault or payment somewhere else. Speaking of fault, the ambulance company billed me immediately and assumed that because my son was hit by a car that it was an auto insurance claim and asked for that information.  Of course these questions are routine and did not drive my son’s health care, but they serve as a constant reminder that our health care system is always about the money trail. Because the United States lacks a national health care program, we must concern ourselves with the ugly word, subrogation, which is an insurance industry term for assigning blame in order to obtain payment or reimbursement. In fact, at 12:04P.M., on October 18th, I received a call from the man who drove the car which hit my child, asking for money to fix his truck. Aside from the ghoulishness and timing of the request, it too reflects on a predominant driver in the U.S. health care system, which is getting paid.
Follow-up Care
Fortunately our follow-up care at Children’s Hospital was a marvel, with concierge-type service from department to department, making fast work of the registration and verifying patient identity quickly, and with humor. Another marvel was the complete lack of any measurable wait time at Children’s Hospital as compared to the follow-up  care we also completed at the trauma center. While at the latter a hospital volunteer retrieved an unconscious man who was unable to speak from the “drive-up” and wheeled him to the X-ray and imaging department. Though I have difficulty imagining what family member would leave someone this vulnerable without an advocate, I was reassured when I saw him alert later in the day when he was waiting for his ride home. In conclusion, a patient advocate is always a good idea during a traumatic event as the family member and the patient may be too upset to make good decisions.
Implications for the Hospital Safety Net
With the implementation of the Affordable Care Act in 2014, more employees will have access to affordable health insurance through federal subsidies and insurance exchanges, regardless of what their employers are doing, so the full-time or part-time work question will become less important. But what remains is an acute shortage of hospital beds, especially in urban trauma centers and this will require an infusion of cash to overcome. Though Disproportionate Share or DSH hospitals like Harborview do receive additional funding from the federal government, it is not enough to finance a building expansion. The resourcing of health care falls to the local hospital district which will have to raise the money through a bond issue or some other means. We cannot afford to staff every hospital with the neurological and other specialty personnel required for Level I Trauma Centers, so surely we must do everything we can to preserve the ones we have. Since 2013 will focus on the budget crisis I hope lawmakers will consider the hospital safety net when they make their cuts.
And this is the healthpolicymaven signing off in real time.
This article was written by Roberta E. Winter, MHA, MPA, a health care journalist, consultant, and mother.