Las Vegas Sun

November 24, 2017

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Heated topic in health care: Does Las Vegas have enough trauma centers?

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SUN STAFF

Ambulances are shown at St. Rose Dominican Hospitals’ Siena Campus in this file photo. St. Rose is one of three Las Vegas hospitals with designated trauma centers, which some health care officials believe is too few for the growing community.

Doctors call it the golden hour.

That’s the first 60 minutes after a person suffers a traumatic injury — maybe from a car accident, gunshot wound or fall — when prompt medical care can save a life. In other words, seconds matter.

Speedy access to critical care has become the crux of a Clark County health care debate that asks, in its starkest terms, is it fair to make badly injured people travel to the other side of town for care to protect the interest of a county-owned hospital and its teaching program?

Emergency crews transport the most severely injured patients to trauma centers, the highly sophisticated units designed to treat people with severe and, sometimes, life-threatening injuries. In recent years, the number of trauma centers has increased across the nation, buoyed by population growth, financial incentives or a combination of both.

Two local hospitals that have applied for trauma centers say it's time for Las Vegas to follow suit, and that not expanding the region's trauma system means compromising patient comfort and safety. Those hospitals contend that growth patterns in the valley — particularly migration to the northwest and southwest quadrants — have resulted in too many people being too far away from prompt trauma care.

And they contend that the deck is stacked against them, due to two things:

• Decision-makers in the process are focusing not on patient care but on protecting the viability of Clark County's publicly funded major hospital — University Medical Center.

• There are conflicts of interest among various elected leaders, government officials and medical directors, who have a vested interest in keeping the status quo in the valley’s trauma system. They all play a role in the process of determining whether to add more trauma centers.

But those on the other end of those accusations say there's no need for expansion. In fact, they say that adding trauma centers would hurt the overall quality of care in the valley by jeopardizing UMC's ability to provide quality care and train doctors. They argue that the companies are motivated by the chance to boost their profits, not on the welfare of local residents.

• • •

Last fall, three Southern Nevada hospitals — Centennial Hills, MountainView and Southern Hills — applied to the Southern Nevada Health District for initial authorization as low-level trauma centers, known as Level 3 trauma centers. The Regional Trauma Advisory Board, which is made up of multiple stakeholders from the health care field, recommended in February that the Health District’s Board of Health deny those applications.

The final decision likely won’t come until May when the Board of Health is expected to vote on it.

It was a momentary sigh of relief for University Medical Center, the county-run hospital that operates the region’s only Level 1 trauma center — the landing spot for patients with the most severe injuries. The possible trauma system expansion doesn’t sit well with UMC officials, who fear it would sap too many patients from the public hospital and jeopardize its residency programs.

But it also frustrated MountainView and Southern Hills, both owned by the Hospital Corporation of America, which felt its applications never got a fair hearing. HCA officials contend the advisory board was biased against them from the start and has a vested interest in keeping the status quo in the valley’s trauma system. Five UMC doctors and nurses are members of the advisory board.

Centennial Hills Hospital, which is part of the Valley Health System, has remained relatively quiet throughout the process. A spokesperson for the Valley Health System, whose parent company is Universal Health Services, sent this statement:

“At Centennial Hills Hospital, we’ve witnessed a continual need for additional (Level 3) trauma services to care for the growing northwest community, and are committed to working in conjunction with the existing trauma system.”

The debate has piqued the interest of local governments and politicians.

In February, North Las Vegas Mayor John Lee sent a letter to the trauma advisory board in support of MountainView adding a Level 3 trauma center. The Las Vegas City Council then threw its support behind the other northwest valley hospital — Centennial Hills — vying for a low-level trauma center. The council passed a resolution in March supporting Centennial Hills’ bid.

Clark County Commissioner Chris Giunchigliani briefly addressed the issue during the commission meeting Tuesday, calling the City Council’s decision to pass such a resolution strange. Giunchigliani, a member of the Board of Health, said the trauma volume didn’t support adding additional trauma centers — and she didn’t want to see the issue devolve into “political shenanigans” deciding the outcome.

“What was broken?” Giunchigliani told the Sun. “The needs were not demonstrated.”

• • •

UMC boasts a 22,000-square-foot trauma unit, roughly the size of four basketball courts, which was built in the early 1990s as the region’s population steadily increased. At that time, it was the only designated trauma center.

That has since changed. In 2005, Sunrise Hospital and Medical Center opened a Level 2 trauma center — adding high-level trauma care on the other side of the Las Vegas Strip — while St. Rose Dominican Hospital-Siena Campus began operating its Level 3 trauma center in the southwest valley. Two years later, UMC received designation as a Level 2 pediatric trauma center as well.

Dr. John Fildes, UMC’s medical director for trauma, said the proposed expansion amounts to “dismantling” the region’s only Level 1 trauma center by creating an oversupply of lower-level trauma centers.

“It’s a pie chart that’s not getting any bigger,” said Fildes, who is a member of the trauma advisory board. “They’re just putting more pieces in the pie.”

Clark County’s population rose steadily for decades until the beginning of the Great Recession, when growth stagnated in 2007 and dropped briefly in 2011 before going back on a steady rise. Now, Clark County is home to an estimated 2.1 million residents, almost 300,000 more than in 2005, when the two trauma centers were added to the system.

Over the next decade, the population is projected to increase to more than 2.5 million, according to a UNLV study. At the same time, the geographical size of the metro area has been expanding too, with most new housing developments popping up in the northwest and southwest valley.

The question remains whether that increased population’s need for trauma care is being met by the current system.

The American College of Surgeons, the agency that accredits trauma centers, requires Level 1 trauma centers to admit 1,200 trauma patients each year. The purpose is to ensure the hospital is seeing enough cases for doctors and nurses to remain clinically competent treating trauma patients. It also guarantees the hospital’s residents gain enough hands-on experience with a variety of trauma cases.

UMC admitted 2,082 trauma patients in 2015, up from a low of 1,607 in 2013. Fildes attributed the increase between 2013 and 2015 as a result of liberalizing the transport of minimally injured infant and elderly patients.

With two new medical schools — at UNLV and Roseman University — expected to begin classes in 2017, anything that poses a risk to residency programs creates concern, said Dr. Barbara Atkinson, founding dean of the UNLV School of Medicine. Newly minted physicians must enter residency programs for additional training in their specialty area before practicing on their own.

Other local hospitals are in the process of adding medical residencies, but it can be a lengthy and costly process. As the region’s Level 1 trauma center, UMC is considered an academic and research institution and has the most robust residency program — training doctors in specialties like emergency medicine, plastic surgery and, soon, orthopedic surgery.

UMC’s fear: A significant drop in trauma cases could lead to its residency programs in specialties like general surgery and orthopedics losing accreditation.

What that would mean for the community: The opportunities for medical specialists to train here would narrow, making it less likely that physicians would build their own practices in the region.

“The more we can train, the more chance we have building out specialties” to help solve the region’s physician shortage, Atkinson said.

The number of people admitted to UMC for trauma care dropped after Sunrise Hospital and St. Rose-Siena opened their trauma centers in 2005. Over the next five years, trauma admissions steadily declined from 2,435 to 1,610.

Fildes worries that drop could happen again.

“That had a profound impact,” he said. “It made training difficult.”

In 2004, the trauma consulting firm Abaris Group conducted a comprehensive assessment of trauma care need in Clark County. Its recommendation was to only add one Level 3 trauma center to the system.

Bill Bullard, senior vice president at the Abaris Group, attributes the drop in UMC’s trauma admissions after 2004 primarily to Sunrise Hospital opening its Level 2 trauma center, which treats more severely injured patients who often require overnight hospitalization.

Adding a Level 3 trauma center shouldn’t affect the number of people admitted to UMC’s trauma unit as dramatically as a Level 1 or 2, because only a small percentage of low-level trauma patients are admitted to the hospital, Bullard said.

St. Rose-Siena admits about 15 percent of its trauma patients, according to Health District data. In 2014, the hospital treated 368 trauma patients.

“So much of this is getting confused — that it’s about taking away the high-acuity cases from UMC, and that’s just not the case,” Bullard said. “UMC does a great job, and we need to make sure it continues to get all of the severe trauma cases.”

Representatives from HCA say that taking away the lower-level cases from UMC would allow the hospital to focus on more complicated cases.

“For residents at UMC’s trauma center to meet their requirement, they have to have high-level trauma cases,” said Jennifer Renner, emergency department service line administrator at HCA. “Level 3 trauma centers take the low-level cases. They don’t threaten the high-level cases.”

Last summer, HCA hired Bullard’s firm to conduct another comprehensive assessment of trauma care need in Clark County.

The HCA-commissioned assessment found that there were more trauma cases occurring in the northwest and southwest parts of the county than in the southeast, where St. Rose-Siena is located. The firm recommended adding one Level 3 trauma center each in the northwest and southwest.

A separate analysis by the Health District also showed significant low-level trauma volume in the area surrounding each of the three hospitals in 2014: 641 low-level cases around MountainView, 541 around Southern Hills, and 277 around Centennial Hills. Cases were counted based on the ZIP codes the hospitals had applied to cover.

Bullard also said adding trauma centers would increase the community’s resilience in the event of a disaster, given the added on-call staff and better resources.

• • •

HCA officials also have raised questions about whether UMC is able to handle its current caseload, saying the county hospital has diverted certain cases. Even so, HCA officials acknowledge the data that could prove an overload of cases is not routinely tracked.

UMC officials flatly denied the accusation.

Fildes said UMC’s trauma center was not overwhelmed or in need of support. Instead, he suggested the Level 3 trauma center applicants may be more motivated by money than expanding patient-care options in the Las Vegas Valley.

Why? The Affordable Care Act has led to more people with insurance, meaning fewer instances of hospitals being stuck with the bill. That change coupled with a trauma activation fee — the cost of hospitals being prepared with both on-call staff and sophisticated resources — has made trauma centers more lucrative than in the past.

“It’s one of the few financial positives surrounding President Obama insuring more Americans,” Fildes said. “Hospitals have kind of caught on to that … They’re just trying to capture as many patients as they can.”

But HCA says opening a trauma center is a costly and difficult process that can take years given the staffing requirements and equipment expenses.

“You have to put all of those resources upfront before you ever get the ability to charge a trauma activation fee,” Renner said. “It can take up to two years or more before you get accredited by the American College of Surgeons and recoup a fee on those trauma services.”

Renner said what drove MountainView and Southern Hills to apply wasn’t financial, but that they’re already seeing a large volume of low-level trauma patients who they would like to keep at their hospitals instead of transferring them to a trauma center.

“The decision to become a trauma center is really about patient quality and care, and the ability to keep patients in the community where they live,” Renner said.

• • •

One of HCA’s biggest concerns, though, is that its hospitals aren’t getting a fair shot at becoming trauma centers.

In a February letter to John Hammond, the EMS and trauma system manager for the Health District, Adam Rudd and Christopher Mowan, the CEOs of Southern Hills and MountainView hospitals, respectively, alleged conflicts of interest and biases among members of the trauma advisory board.

The board comprises a number of nurses and doctors from UMC, Sunrise and St. Rose-Siena, the three existing trauma centers in the valley. Centennial Hills Hospital’s CEO also sits on the advisory board.

“Specifically, the (board) is comprised primarily of stakeholders — administrators from the existing trauma centers and other persons involved in providing emergency medical services,” they wrote. “Thus, each of its members has a personal interest at stake and arguably a bias in favor of or against a particular applicant.”

In the letter, the CEOs urged the board to bring in a third party to evaluate whether the valley needs any additional trauma centers.

“We’ve said from the very beginning, if the third party comes in and says don’t expand it, we will live with that decision,” Renner said. “We really just want that objective person to say so.”

At its February meeting, the trauma advisory board voted to establish a needs-based assessment task force — including representatives of Centennial Hills, MountainView and Southern Hills as well as future applicants and other stakeholders — to develop metrics for assessing when new trauma centers should be approved.

But HCA still has reservations about the task force.

“I feel it’s a formality and a way to stall, more than an actual committee to get to what the real needs are,” Renner said. “I would prefer that a third party come in instead.

Irwin Redlener, a professor and director of the National Institute for Disaster Preparedness at Columbia University, described the board’s composition as a Catch-22.

“Here’s the tension on this: You want people who are experts in these areas. On the other hand, you don’t want people who are making decisions based on their home institutions,” Redlener said. “But, on the other hand, you don’t need to be a trauma surgeon to come up with the right answer.”

Funding for this kind of third-party analysis remains a challenge. State and federal money slated for health-system planning has essentially “dried up,” Redlener said.

In these types of situations playing out in Las Vegas and across the country, Redlener said third-party input is critical for a fair assessment of trauma need in a community.

“I think the cleanest way to do this is to not have this paid for by any particular organization that’s got a vested interest in the outcome,” Redlener said. “It just doesn’t bring up the kind of questions that it would if one of the parties has a lot of stake in the game.”

As the months-long debate continues, Fildes said residents should rest assured that the current trauma system is serving patients well. Fildes wouldn’t oppose a third-party assessment of the region’s future needs, although he’s not sure it would add much new information.

“In the end, everyone wants to have an evidence-supported decision until the evidence doesn’t support their bias,” he said.

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