In 2009, nearly one in three deaths from traumatic injury in Arkansas may have been preventable. A scientific study by a panel of trauma experts, studying trauma cases from that year, found that 9 percent of the deaths were "frankly preventable," and another 21 percent were "possibly preventable." Arkansas's preventable mortality rate was the worst in the nation, the American Medical Society reported at that time.
Patients were bleeding to death before they could get to a hospital, or improperly intubated, or transported to a facility that did not have the expertise to treat them. There were all manner of problems because, unlike every other state in the union, Arkansas had no coordinated statewide system to get the injured to the right place quickly.
The year 2009 was a watershed in trauma care in Arkansas, thanks to the creation of the Arkansas Trauma System of integrated medical care throughout the state. Since then, the study, which compared 2009 trauma patient data to 2013 data, found that preventable deaths had been cut nearly in half, to 16 percent.
An informal analysis by a committee of medical professionals of more recent data suggests the rate could be down to 14 percent, Dr. Charles Mabry, a Pine Bluff surgeon and one of the leaders in the trauma system startup, said.
Reporting in June to colleagues on the Governor's Trauma Advisory Council, which has been crucial to the implementation of the system, Mabry credited the improvement in survival rates to ongoing education, rather than "gizmos or gadgets." He judged the education portion of the system to be responsible for 90 percent of the improvement in the reduction of preventable deaths.
But the trauma system's delivery of that education — the Arkansas Trauma Education and Research Foundation — no longer exists. The Trauma Section of the Arkansas Department of Health canceled its nearly $1.2 million contract with ATERF in May, saying it had not worked with ADH to correct its billing practices.
Trauma professionals are also unhappy that this year the system will not receive unspent dollars that since 2009 have been carried over from the previous year's budget. They say those funds have been used to meet unanticipated needs and develop new programs successful at saving lives.
A trauma system is a classic example of the whole being made into something greater than the sum of its parts. With the creation of the trauma system, the state's dozens of existing hospitals were bound into a network in which each is identified by level of medical expertise, staffing and equipment. Information and coordination are at the heart of the system, which includes a "dashboard" that provides real-time information on availability and capacity at area hospitals, a call center that relays dashboard information to emergency transport personnel, a registry that keeps data on all patients treated in the system, and year-round education for medical professionals, including paramedics, first responders, doctors and trauma nurses. The last state in the nation to implement a trauma system, Arkansas is now recognized nationally, doctors say, for the improvements it's made in patient care.
Today, 64 hospitals in Arkansas are trauma-designated, up from a mere 37 in 2012, though lower than the 70 participating in 2014.
Tammy Alexander is one of those people who before Arkansas changed the way it provided trauma care would almost certainly have died of the injuries she suffered March 15.
On that day, Alexander, 56, a psychotherapist at the Central Arkansas Veterans Healthcare System in North Little Rock, was headed home to Beebe on U.S. Highway 67-167 when a southbound SUV lost control and barreled through the cables dividing the highway, hitting her head-on. (The driver of the SUV said he'd lost control when an ember from his cigarette went into his eye).
The impact spun Alexander's car into the barrier cables "and they acted like a sling shot," she said, sending her back across both northbound lanes of traffic and into trees along the side of the road.
When the car came to a stop, she tried to get out, "but nothing in my body would move." Alexander looked down at her arm and saw bones and flesh. "I thought, 'Oh, that's why I can't get out of the door.' " Someone — she doesn't know who — called 911 and ambulances with two paramedics arrived quickly on the scene. One of them crawled into the car from the back window, stabilized Alexander's head and neck, and kept her conscious by talking and asking questions about her family; she even prayed with her. When rescuers using the Jaws of Life came to extricate Alexander from the car, she guided them away from Alexander's shattered left arm. It took an hour to pry the car open; Alexander was then airlifted to the University of Arkansas for Medical Sciences. The helicopter got her to a waiting trauma team at the hospital in six minutes, "and once I landed, there was a flurry of activity," she said, as the trauma team took over. She was conscious but her blood pressure was bottoming out; an ultrasound machine indicated she was bleeding internally. Surgeons went to work opening her up to stop the bleeding and tending to the compound fracture of the arm and broken femur. She spent five days in the intensive care unit and another six in a trauma step-down room, and she's since had to have bone grafts. "There are bones out there on 67-167 that came out of my arm," she said good-naturedly.
Alexander credited the trauma system — and divine providence — for the fact that she is alive today. And, she is not just alive: She is walking and working two days a week.
Terry Collins, a registered nurse and director of trauma services for the College of Medicine at UAMS, said before the new trauma rules were put into place, Alexander would have been taken to the closest hospital — North Metro Medical Center in Jacksonville, which operates at the lowest level in the trauma system "where they don't have surgeons in house 24/7 or the ability to go to interventional radiology and stop the bleeding. She very likely would have died before she got transferred [to UAMS]. And that's what we saw before the trauma system: People bled to death."
"Patients have such tremendous reserves, they can bleed out without looking sick," Texarkana surgeon and trauma system leader Dr. Jim Booker said. Now, trauma-designated hospitals have what is called a massive transfusion protocol to identify such patients and intercede early, and trauma personnel have begun to reintroduce the use of tourniquets to first responders, including police. The ability to train lay people in the use of tourniquets "is on our bucket list," Collins said. The carry-forward funds could have been used to take tourniquets off the list.
Since the implementation of the trauma system, the number of patients requiring hospital care because of injury coming to UAMS has increased from around 700 a year to 2,300. In response, UAMS has increased its trauma surgical team from two — Dr. John Cone and Dr. Ron Robertson — to seven, and two more doctors will be hired soon. That worked well for Gary Worsham, who on Feb. 23 found himself underneath 6,000 pounds of steel in the form of 10 I-beams. They collapsed on Worsham, 53, early one morning while he was working at AFCO Steel in Little Rock. His co-workers were on break, so he wasn't discovered until he'd been lying beneath the beams for around 20 minutes. "Everybody thought I was dead," Worsham said.
Worsham was rushed to UAMS, where his trauma score — a measure of the severity of injury — was a sky-high 41. (By comparison, Alexander's was 17; at 75, you don't survive.) Worsham said he was "swollen as a pig" when he arrived at the ER. The trauma team went to work to stop the bleeding from his jumbled and crushed organs; "I coded twice," meaning his heart stopped, Worsham said, "and they didn't give up on me." Besides his internal injuries, he also had a fractured pelvis, a shattered kneecap and a broken left leg. Worsham said he was on an artificial respirator for a month.
"They didn't give up on me," Worsham kept repeating. "They watched me 24/7, around the clock. ... They saved me. Now I'm on the walker, but I can move. My insides are kind of moved around, but I am alive and I thank God for that."
The health department's Trauma Section oversees the business of the system, such as budgeting and grant-making, maintaining the Trauma Registry and oversight of the trauma communications center. The 24-member (two ex-officio) Governor's Trauma Advisory Council, whose members include representatives from the Trauma Nurses Society, the Arkansas Medical Society, the American College of Surgeons, the Arkansas Ambulance Association and other groups, as well as legislative appointments, provides the expertise and advises the department on how the various components of the system can better function.
Mabry, the chairman of the Quality Improvement/Trauma Regional Advisory Council committee of the trauma council, reported the good news about the reduction in preventable trauma deaths to the council at its last meeting on June 21. By doing so, he underscored fears that the department's decision to cancel its contract with ATERF could undermine the impressive progress made these past several years.
Mabry's report also followed a decision by Booker, the Texarkana surgeon, to quit consulting with the Trauma Section.
In a June 16 letter to Arkansas Department of Health Director Dr. Nathaniel Smith, Booker said he was stepping down because of changes the department was making to the trauma system.
"The education process within the state has been completely halted with no backup plan," Booker wrote. "In this scenario, we will be unable to enforce the educational requirements for hospital designation." He described the changes as "penny-wise and pound foolish." Booker was also unhappy, he wrote Smith, that his opinion on not continuing the ATERF contract had not been sought and, more troubling, that ADH staff had been instructed not to inform him of the cancellation of the contract.
The health department's contract with ATERF, which dated to 2012, was supposed to run through the 2017 fiscal year (which began July 1, 2016). ATERF, a nonprofit, has provided dozens of classes yearly across Arkansas since 2012 as part of the trauma system's strategy to improve outcomes. State subsidies allowed ATERF to offer the classes for as little as $100 to $150. When offered directly from the American College of Surgeons, the same classes could cost as much as $1,400. Just as importantly, ATERF has taken the classes to hospitals around the state rather than require personnel to come to Little Rock, which has increased class attendance dramatically, according to trauma surgeon Robertson. The beauty of ATERF's involvement, doctors say, is that it has been able to modify regular courses to fit the particular needs of Arkansas. For instance, when Trauma Registry data showed that paramedics in one part of the state were having problems successfully intubating patients, ATERF sent a teaching team with airway mannequins to correct the problem.
At the June trauma council meeting, where he was thanked for his service to the trauma system, Booker's voice cracked with emotion as he told his colleagues that it was "incredibly distressing that changes are being made by the finance department that will affect trauma outcomes. The people making the decisions don't have a clue on the clinical impact. ... These changes will increase preventable deaths. These changes will cause Arkansans to die."
Without state funding, ATERF is now defunct. The health agency says it owes the state money, and has asked Legislative Audit for a study. Former ATERF officers say the nonprofit also has unpaid bills.
There have been grumblings about ATERF for several years, including criticism of the nonprofit's choice of swanky Big Cedar Lodge in Missouri for conferences, and its alcohol bills from meetings. Former ATERF director Claudia Parks-Miller simultaneously acted as the nonprofit's lawyer, which meant she signed checks to herself for legal services rendered. But Dennis Robertson, who took over the day-to-day running of ATERF from an ailing Parks-Miller in January, said vendor fees rather than state dollars picked up the bar tabs.
Dr. Booker said he believed that some at the health department thought ATERF was paying doctors (including himself) too much to teach the classes. But, he said, teaching required doctors to leave their offices, which cost them money, to spend time out in the state. "Who else wants to go to Crossett, Arkansas?" he asked. "There are just so many [doctors] who want to do it."
ADH general counsel Robert Brech attended the June trauma council meeting to explain the health department's problems with the ATERF contract. ATERF, which had been paid by the department since 2012 under a fee-for-service arrangement, declined in February to provide receipts for expenses to the health department when requested. ADH maintains that ATERF's pay should have been "reimbursement for actual expenses ... . There is no doubt," Brech told the Trauma Advisory Council members.
When Parks-Miller argued in February that the nonprofit's fee-for-service contract did not require it to provide receipts that detailed its expenses, Brech informed her that the health department would not pay any invoices until the receipts were turned over. "Well, right the next day, they delivered $90,000 worth of invoices to the health department," he told the trauma council. The department did not pay the invoices.
Brech acknowledged that the department shouldered some of the blame for the improper reimbursement of ATERF in the past. "Since the department did not ask for receipts, the department is at fault. ... We should have been asking for receipts at the beginning." But, he added, ATERF "was making quite a profit off these classes." The organization, after three years, "had a half million cash in the bank."
ATERF's most recent tax form, for the tax year ending June 2014, reported $768,687 in net assets. But it has virtually no money in the bank now, Dennis Robertson said. The 990 form was a "snapshot in time," Robertson said, that did not reflect outstanding debt that was paid off after the form was filed.
ATERF hired him, Robertson said, to build up the corpus of the nonprofit as a cushion against unanticipated debt and to be able to one day provide education without state funding.
(Robertson was an aide to U.S. Sen. David Pryor and a former lobbyist for the Arkansas Electric Cooperatives and former head of Pinnacle Business Solutions. He is also Dr. Ron Robertson's brother.)
When the health department canceled the contract with ATERF, the nonprofit could not recoup the $125,000 it paid earlier in May to put on a trauma education update conference in Rogers, Robertson said, and in total, ATERF was out $314,000 for services performed.
ATERF has trained 3,500 medical professionals since 2012, Dennis Robertson said, addressing shortcomings trauma doctors in Arkansas had identified.
The nonprofit had been budgeted to receive $1,152,033 in fiscal year 2017. The money will still go to education, said Brech and Greg Brown, the health department's branch chief of trauma, public health preparedness and EMS since January, but they had no specifics.
Brown told the Trauma Advisory Council that rumors that he "hated education" were wrong, and that the health department was "totally committed" to renewing training. "How that will look going forward, we'll see," and that "local people giving local education," such as occurred through ATERF, "you can't argue with that."
Mabry, though he sounded the alarm about the need for continued education, and credited ATERF for supplying "the needed resources, staff and ramp-up capability" in his report to the Trauma Advisory Council, said he expects the state will now send education grants directly to hospitals. The American College of Surgeons will continue to offer classes as it always has.
ATERF supporters have known the nonprofit was in trouble with agency finance personnel since the beginning of the year, when former trauma chiefs at the health department published a statement warning that the agency, after an internal review, was reinterpreting the way the ATERF contract should have been handled.
ATERF maintains it was the health department's idea that the nonprofit should be compensated in a fee-for-service arrangement. The statement, put out by Brown's predecessor at the health department, Bill Temple, and then-Trauma Section Chief Renee Joiner, who has also left the health department, said, "The contract was administered as fee-for-service contract for the entire 4 1⁄2 years [it was maintained]. ATERF submitted invoices, was paid the negotiated price for a course and the contract was renewed four times over four years under this fee-for-service administration. ATERF delivered 231 courses and fee for service invoices were submitted to the Health Department for each course. The Health Department paid every invoice without question or indication of a problem over the 4 1/2 years."
Dr. Todd Maxson, the head of trauma care at Arkansas Children's Hospital, intimated that some of the state agency's problems with the trauma system — and perhaps the legislature's as well — have to do with the fact that a small core of health professionals has been involved so deeply, serving on the state trauma council and Arkansas's seven regional trauma councils, consulting with the health department and teaching classes.
"There are always going to be people who don't like [the system] because it moves their cheese in some way," Maxson added.
Maxson said that thanks to ATERF, "We have cut preventable mortality in this state in half. To reel back in the control of that, the system, to redirect the money, to eliminate an effective education plan, I just think it's a travesty."
Maxson acknowledged that he was paid by ATERF to teach, but said that he took vacation days from work to do so, and that he was paid less to teach than he would have been paid at work.
If ATERF has done something illegal, Maxson said, he would support "any recourse necessary." But, he said, the department should have consulted with the state's trauma care experts, and had a substitute educational plan in place before ending its contract with ATERF. He said medical personnel will still be able to take classes offered by the American College of Surgeons, but that they will be fewer, more expensive and less accessible, since most will be offered in Little Rock.
Maxson also quit consulting with the Trauma Section in June. He said he did so because of his new duties as head of the hospital's Burn Center.
The trauma system leadership expected to receive $4.5 million in carry-forward funds to add to the $19.2 million trauma budget for the 2017 fiscal year that began July 1.
But the legislature reduced the sum to $3.7 million, and, thanks to an amendment by Sen. Missy Irvin (R-Mountain View), none of the unspent dollars will carry over to the trauma system. They will instead be used to purchase long-acting contraceptives for state health clinics and on health agency programs related to stroke and heart attacks, programs the agency advocated for.
In an interview, Irvin, who serves on the Joint Budget Committee of the legislature, said she "really did her homework" before deciding to move the carry-forward funds out of the trauma budget and into to the health department. The system should not expect to be able to use its unspent dollars when "it's hard to find new funding for new programs," Irvin said.
Mabry and others at the June trauma council meeting told Brown they would have liked to have had a heads-up from the health department so they could have explained to the legislature the importance of the carry-forward funds before the decision was made to send them elsewhere.
But Irvin, who is married to a doctor, said trauma leadership had the opportunity to come before the legislature. Maxson "never once appeared before the public health committee," she said.
Though Brech and Brown declined to discuss the ATERF situation with a reporter, they did discuss trauma system funding.
Brech said the health department's budget of $53 million has been flat since 2001, adjusting for inflation. Moving the unspent trauma budget funds into the department's general budget will make up for that somewhat. Brown added that the trauma council members, while professing surprise at the loss of the dollars, had known since May, because "we didn't allow them to budget it."
Brown said the trauma budget had allocated $165,000 for special evidence-based projects that would previously have come out of carry-forward money.
"I think members of the [trauma council] understand" how funding works, Brown said.
"I think the [trauma council] needs to understand that's not their money that they would have forever," Brech said of the unspent funds.
Another suggestion of pullback in the trauma system is the fact that there are six fewer hospitals in the trauma system than there were two years ago.
Out of Arkansas's 76 hospitals, 64 are designated. (Designation is voluntary; some hospitals have never been part of the system.) But 33 of the 64 are deficient in meeting trauma system requirements, according to health department spokeswoman Marisha DiCarlo, and in danger of losing their designation.
The legislation that created the trauma system prevents the public from knowing which hospitals have deficiencies. But the health department has published a list of designated hospitals periodically, however, so changes can be tracked.
The number of hospitals designated as Level I, the highest, has increased thanks to the addition of out-of-state participants in Memphis and Springfield, Mo. Level I hospitals are required to have a number of trauma specialists on duty at all times, including neurosurgeons and orthopedic surgeons, and also have a general surgery residency program. They include UAMS, Arkansas Children's Hospital, Le Bonheur Children's Hospital and the Regional Medical Center (The Med) in Memphis, and CoxHealth and Mercy Hospital in Springfield. In-state Level I hospitals are funded at $1 million a year; out-of-state hospitals are compensated based on the number of Arkansas patients they care for.
The number of Level II hospitals — comprehensive trauma centers required to have trauma-trained surgical staff — has fluctuated between four and five: Today, Baptist Health Medical Center, CHI St. Vincent in Hot Springs, CHI St. Vincent in Little Rock, Mercy Hospital in Springfield and Washington Regional in Fayetteville are Level II. In-state Level II hospitals will receive around $500,000 in 2017.
But several hospitals have slipped in designation. Jefferson Regional Medical Center in Pine Bluff has downgraded from II to III (requiring only "consistent general surgical coverage," according to a health department publication). Chicot Memorial Medical System, a Level III in 2015, is now a Level IV, the designation for community hospitals without consistent surgical service but with providers who know how to evaluate, stabilize and rapidly transfer patients. Magnolia Regional Medical Center, once a III, is also now a IV. Level III hospitals receive around $120,000 and Level IV around $25,000.
Johnson Regional Medical Center, a Level III in 2012, is no longer part of the system, which means that Clarksville is without a trauma-designated hospital.
Level IV hospitals in Arkadelphia, Walnut Ridge and Ashdown, have also dropped out of the system.
It's important that all patients have "ready access" to a trauma-designated hospital, trauma surgeon Ron Robertson said, "but as the system develops, you'll find that the [geographic] need for everybody to be a trauma center goes away." But, he added, "What you hope drives [the decision to leave the system] is data-based evidence" that the service is redundant.
Meeting surgeon requirements may get harder: Robertson, who has taught Advanced Trauma Life Support classes to thousands of Arkansas doctors, said about half the state's 71 general surgeons are getting ready to retire in the next few years without replacements coming to fill their spots. "We could find ourselves with a shortage," he said. Already there is a shortage of neurosurgeons; Jefferson Regional dropped to a Level III because it could not hire a neurosurgeon to be on call, Robertson said.
Arkansas Children's Hospital trauma chief Maxson said the hospital designation is "moving in the wrong direction."
"In some ways, that's OK" that some hospitals have decided to withdraw from the trauma system," Maxson said, if there was redundancy in delivery and dollars are tight. But, he added, communities need to know if their hospitals "have chosen not to meet Arkansas standards," as a matter of public health.
Ideally, however, Maxson said, "I think a trauma designation ought to be mandatory." Or, he said, if not, nondesignated hospitals should not be allowed to accept trauma patients, which is how Ohio and Oregon handle their systems.
Health department section chief Brown, however, said that just because a hospital is not designated doesn't mean it offers poor or subpar care.
A digital timer hangs on the wall of one of UAMS' trauma emergency rooms. Robertson uses it to make sure he's hitting all his goals: By three minutes, his patient should have vitals taken, blood drawn, be ready for a chest X-ray; by "seven, eight or nine minutes" Robertson should have seen the X-ray "and we're going to the operating room or the CT scanner down the hall. By 10 minutes, I am ready to make a definitive diagnosis." A map above the clock shows where all members of the trauma team should be standing.
But before the clock starts at the ER, the medic has called the charge nurse to inform her of the incoming patient's injuries and the charge nurse has assembled the trauma team of doctors and nurses and technicians. Sometimes, thanks to the relatively new Trauma Imagery Repository, the doctor has been able to see a CT scan taken of the patient before he's even on the road to UAMS. There's a blood bank waiting. It is a sign of UAMS' commitment to its trauma care that it keeps an operating room — its main "profit center," Robertson said — empty so there will be no waiting when it is needed.
Asked if he was concerned that the legislature thinks the trauma system is funded well enough, Robertson said he had concerns.
"I get it: $20 million is a lot of money," Robertson said, "and a lot of projects I'm sure people believe are equally as important as the trauma system. But I don't think you'll find something as labored over or as scientifically tested as rigorously as we have" to show that the system saves lives. Saving lives also equates to saving money: Since most trauma patients are young, keeping them alive and able to work is a plus for the economy.
With ATERF dismantled and the carry-forward funds diverted to other uses, Ron Robertson and Terry Collins worry the trauma system could lose ground rather than keep hammering away at preventable mortality.
"Sixteen percent mortality is not acceptable for those of us that live and breathe this, who know the patients by name, that take care of these patients," Collins said. "This trauma family wakes up every day and knows our job is to save lives, and we're blessed, I believe, that we have the opportunity to save lives. It's also a responsibility and a challenge to be the best that we can be, and to continue that work we have done to drive down our preventable mortality rate. We've come a long way, but we've got a lot of work to do."
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