EDITORIALS
F I G U R E . Example of the incremental cost comparison of
Personnel Cost $3,000 per year differential between ALS and BLS provider Each person works 2,496 hours/year (48 hours per week) A 24-hour unit, 365 days = 8,736 hours per year No. of ALS full-time equivalents (FTEs) per unit = 8,736/2,496 = 3.5 FTEs Seven units x 3.5 = ALS FTEs = 24.5 total ALS FTEs Total personnel cost differential = 24.5 x $3,000 = $73,500 per year Nonpersonnel Cost ALS equipment/supplies, approximately $15,000 per unit Average life expectancy of equipment - seven years Ten full sets of ALS equipment required for seven units (reserve + on line) $15,000 x 10 = $150,000 Average life expectancy of equipment of seven years = $21,428 annual cost Total Incremental Cost Personnel $73,500 Nonpersonnel $21,428 $94,928 Per-Transport Cost $94,928 per year / 33,000 transports = $2.88 per transport
$500,000). W e b e l i e v e t h a t ALS w i t h a f i r s t - r e s p o n d i n g t i e r c a p a b l e of r a p i d d e f i b r i l l a t i o n is t h e m i n i m u m a c c e p t a b l e l e v e l of care i n a n u r b a n or s u b u r b a n E M S s y s t e m . J u s t as p o l i c e a n d fire p r o t e c t i o n is m a n d a t e d b y law, w e b e l i e v e t h e p u b l i c h a s a r i g h t to p r o m p t , t r a i n e d , e q u i p p e d ALS care a n d t h a t s u c h a l e v e l of e m e r g e n c y r e s p o n s e c a n b e prov i d e d b y u p g r a d i n g a n e x i s t i n g BLS or m i x e d BLS/ALS system at a modest incremental expense. The only exception would be in rural areas where the population density and v o l u m e of E M S c a l l s c o u l d n o t j u s t i f y t h e e x p e n s e of m a i n t a i n i n g a n all-ALS s y s t e m . It is t i m e for e m e r g e n c y
an alJ-ALS system versus a m i x e d BLS/ALS. Data from Richmond, Virginia, comparing the per-transport cost of having 14 units at the ALS level versus seven ALS and seven BLS.
p h y s i c i a n s i n all u r b a n a n d s u b u r b a n p r a c t i c e e n v i r o n m e n t s s e r v e d b y less o p t i m a l l y c o n f i g u r e d E M S s y s t e m s to p r e s e n t t h e s e a r g u m e n t s to t h e i r l o c a l g o v e r n m e n t offic i a l s to d e m a n d a s y s t e m u p g r a d e as s o o n as p o s s i b l e .
Joseph P Ornato, MD Edward M Racht, MD Joseph J Fitch, PhD John F Berry, MPA Internal Medicine Section of Emergency Medical Services Medical College of Virginia Richmond 1. Keller RA, Forinash M: EMS in the United States: A survey of providers in the 200 most populous cities. ] Emerg Med Serv 1990;15:79-100. 2. Braun O, McCallion R, Fazackerley J: Characteristics of midsized urban EMS systems. Ann Emerg Med 1990;19:536-546. 3. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 4. Eisenberg MS: Quality assurance: Is it possible? EMS Forum, ACEP Scientific Assembly, San Francisco, November 1987. 5. Overton J: The use of advanced procedures on presumptively defined basic life support ambulance responses. Presentation to Board of Trustees, Metropolitan Ambulance Services Trust, Kansas City, Missouri, November 1989. 6. Goldberg RJ, Zautcke JL, Koenigsberg MD, et al: A review of prehospital care litigation in a large metropolitan EMS system. Ann Ernerg Med 1990;19:557-561. 7. Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinalcord injury. Results of the second national acute spinal cord injury study. N EngI J Med 1990;322:1405-1411. 8. Eisenberg MS, Hallstrom AP, Copass MK, et al: Treatment of ventricular fibrillation with emergency medical technician defibrillation. JAMA 1984;251:1723-1726. 9. Weaver WE), Cobb LA, Fahrenbruch CE, et al: Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl ] Med 1988;319:661-666. 10. Ornato Jp, Craren EJ, Gonzalez ER, et al: Cost-effectiveness of defibrillation by emergency medical technicians. Am J Emerg Med 1988; 6:108-112.
What is 'Major Trauma?' In t h e i r c o n t r i b u t i o n t o t h i s i s s u e of Annals, B a x t a n d U p e n i e k s call o u r a t t e n t i o n to t h e c h a r a c t e r i z a t i o n of injury. T h e y p r o p o s e a d e f i n i t i o n of m a j o r t r a u m a b a s e d o n the services provided, findings at operation, and outcome (death) for i n j u r e d p a t i e n t s . O t h e r s h a v e p r o p o s e d defini-
152/1470
t i o n s of m a j o r t r a u m a b a s e d o n t h e l i k e l i h o o d of d e a t h a s s o c i a t e d w i t h i n j u r i e s of g i v e n s e v e r i t y . 1 D o e s e i t h e r approach "fully" define major trauma? T h e I n j u r y S e v e r i t y S c o r e (ISS) 2 w a s d e v e l o p e d to e v a l u ate motor vehicle accident victims who sustained multi-
Annals of Emergency Medicine
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ple injuries. This scoring s y s t e m has been used w i d e l y in the s t u d y of t r a u m a because it is reproducible and highly predictive of mortality. 3 ISS is a n u m e r i c a l m e a s u r e of ana t o m i c injury in body regions and allows the c o m p a r i s o n of injury severity and o u t c o m e in different p a t i e n t populations. The ISS m a k e s possible the s t u d y of t r a u m a interventions by controlling for the severity of injury in groups r e c e i v i n g care different from c o n t r o l groups. Few h a v e argued t h a t the ISS fully characterizes trauma, even in the p r e d i c t i o n of m o r t a l i t y . A d d i t i o n of a d e t e r m i n a t i o n of physiologic d e r a n g e m e n t (the T r a u m a Score) 4 and p a t i e n t age r e s u l t s in a m e a s u r e m e n t w i t h m a r k e d l y i m p r o v e d ability to quantify the probability of survival. 1 However, the ISS and related t r a u m a scales do n o t categorize t r a u m a patients on the basis of resources required for their care. See related article, p 1396. Baxt and U p e n i e k s have developed a definition of major t r a u m a m o r e closely related to the resources required to care for injured patients in their institution. Thus, it is not surprising that the ISS does n o t segregate p a t i e n t s into major and m i n o r categories based on this n e w definition. We are r e m i n d e d that planning for the care of the t r a u m a p a t i e n t r e q u i r e s k n o w l e d g e of t h e c a p a b i l i t i e s t h a t a t r a u m a facility m u s t m a i n t a i n in order to o p t i m a l l y treat the i n j u r e d p a t i e n t . F r o m this s t a n d p o i n t , e v a l u a t i o n of Baxt and U p e n i e k s ' d e f i n i t i o n of m a j o r t r a u m a by the T h e r a p e u t i c I n t e r v e n t i o n Score, 5 a m e t h o d of e x p l i c i t l y
19:12 December 1990
m e a s u r i n g m e d i c a l r e s o u r c e use, w o u l d be i n f o r m a t i v e . Such an operational definition of trauma, due to its subjective e l e m e n t s (eg, the definition of positive operative findings as " t r a u m a t i c injuries that could have been lifethreatening"), is less u s e f u l in c o m p a r i n g o u t c o m e s of t r a u m a care in different p a t i e n t populations. Thus, n e i t h e r the ISS nor the operational definition of major t r a u m a proposed by Baxt can be said to fully characterize major trauma. Rather, the approaches to the evaluation of t r a u m a care represented by both are c o m p l e m e n t a r y and n e c e s s a r y to t h e c o m p l e t e u n d e r s t a n d i n g of trauma. Terence D Va]enzuela, MD, FACEP, FACP Section of Emergency M e d i c i n e D e p a r t m e n t of Surgery University of Arizona College of Medicine Tucson 1. Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: The TRISS method. J Trauma 1987;27:370-378. 2. Baker SP, O'Neill B, Haddon W, et ah The injury severity score: A method for describing patients with multiple injuries and evaluating emerk gency care. J Trauma 1974;1&187-196. 3. Copes WS, Champion HR, Sacco WJ, et ah The injury severity score revisited. J Trauma 1988;28:69-77. 4. Champion HR, Sacco WJ, Camazzo AJ, et ah The trauma score. Crit Care Med 1981;9:672-676. 5. Keene AR, Cullen DJ: Therapeutic intervention scoring system: Update 1983. Grit Care Med 1983;11:1-3.
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F I G U R E . Example of the incremental cost comparison of
Personnel Cost $3,000 per year differential between ALS and BLS provider Each person works 2,496 hours/year (48 hours per week) A 24-hour unit, 365 days = 8,736 hours per year No. of ALS full-time equivalents (FTEs) per unit = 8,736/2,496 = 3.5 FTEs Seven units x 3.5 = ALS FTEs = 24.5 total ALS FTEs Total personnel cost differential = 24.5 x $3,000 = $73,500 per year Nonpersonnel Cost ALS equipment/supplies, approximately $15,000 per unit Average life expectancy of equipment - seven years Ten full sets of ALS equipment required for seven units (reserve + on line) $15,000 x 10 = $150,000 Average life expectancy of equipment of seven years = $21,428 annual cost Total Incremental Cost Personnel $73,500 Nonpersonnel $21,428 $94,928 Per-Transport Cost $94,928 per year / 33,000 transports = $2.88 per transport
$500,000). W e b e l i e v e t h a t ALS w i t h a f i r s t - r e s p o n d i n g t i e r c a p a b l e of r a p i d d e f i b r i l l a t i o n is t h e m i n i m u m a c c e p t a b l e l e v e l of care i n a n u r b a n or s u b u r b a n E M S s y s t e m . J u s t as p o l i c e a n d fire p r o t e c t i o n is m a n d a t e d b y law, w e b e l i e v e t h e p u b l i c h a s a r i g h t to p r o m p t , t r a i n e d , e q u i p p e d ALS care a n d t h a t s u c h a l e v e l of e m e r g e n c y r e s p o n s e c a n b e prov i d e d b y u p g r a d i n g a n e x i s t i n g BLS or m i x e d BLS/ALS system at a modest incremental expense. The only exception would be in rural areas where the population density and v o l u m e of E M S c a l l s c o u l d n o t j u s t i f y t h e e x p e n s e of m a i n t a i n i n g a n all-ALS s y s t e m . It is t i m e for e m e r g e n c y
an alJ-ALS system versus a m i x e d BLS/ALS. Data from Richmond, Virginia, comparing the per-transport cost of having 14 units at the ALS level versus seven ALS and seven BLS.
p h y s i c i a n s i n all u r b a n a n d s u b u r b a n p r a c t i c e e n v i r o n m e n t s s e r v e d b y less o p t i m a l l y c o n f i g u r e d E M S s y s t e m s to p r e s e n t t h e s e a r g u m e n t s to t h e i r l o c a l g o v e r n m e n t offic i a l s to d e m a n d a s y s t e m u p g r a d e as s o o n as p o s s i b l e .
Joseph P Ornato, MD Edward M Racht, MD Joseph J Fitch, PhD John F Berry, MPA Internal Medicine Section of Emergency Medical Services Medical College of Virginia Richmond 1. Keller RA, Forinash M: EMS in the United States: A survey of providers in the 200 most populous cities. ] Emerg Med Serv 1990;15:79-100. 2. Braun O, McCallion R, Fazackerley J: Characteristics of midsized urban EMS systems. Ann Emerg Med 1990;19:536-546. 3. Eisenberg MS, Horwood BT, Cummins RO, et al: Cardiac arrest and resuscitation: A tale of 29 cities. Ann Emerg Med 1990;19:179-186. 4. Eisenberg MS: Quality assurance: Is it possible? EMS Forum, ACEP Scientific Assembly, San Francisco, November 1987. 5. Overton J: The use of advanced procedures on presumptively defined basic life support ambulance responses. Presentation to Board of Trustees, Metropolitan Ambulance Services Trust, Kansas City, Missouri, November 1989. 6. Goldberg RJ, Zautcke JL, Koenigsberg MD, et al: A review of prehospital care litigation in a large metropolitan EMS system. Ann Ernerg Med 1990;19:557-561. 7. Bracken MB, Shepard MJ, Collins WF, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinalcord injury. Results of the second national acute spinal cord injury study. N EngI J Med 1990;322:1405-1411. 8. Eisenberg MS, Hallstrom AP, Copass MK, et al: Treatment of ventricular fibrillation with emergency medical technician defibrillation. JAMA 1984;251:1723-1726. 9. Weaver WE), Cobb LA, Fahrenbruch CE, et al: Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest. N Engl ] Med 1988;319:661-666. 10. Ornato Jp, Craren EJ, Gonzalez ER, et al: Cost-effectiveness of defibrillation by emergency medical technicians. Am J Emerg Med 1988; 6:108-112.
What is 'Major Trauma?' In t h e i r c o n t r i b u t i o n t o t h i s i s s u e of Annals, B a x t a n d U p e n i e k s call o u r a t t e n t i o n to t h e c h a r a c t e r i z a t i o n of injury. T h e y p r o p o s e a d e f i n i t i o n of m a j o r t r a u m a b a s e d o n the services provided, findings at operation, and outcome (death) for i n j u r e d p a t i e n t s . O t h e r s h a v e p r o p o s e d defini-
152/1470
t i o n s of m a j o r t r a u m a b a s e d o n t h e l i k e l i h o o d of d e a t h a s s o c i a t e d w i t h i n j u r i e s of g i v e n s e v e r i t y . 1 D o e s e i t h e r approach "fully" define major trauma? T h e I n j u r y S e v e r i t y S c o r e (ISS) 2 w a s d e v e l o p e d to e v a l u ate motor vehicle accident victims who sustained multi-
Annals of Emergency Medicine
19:12 December 1990
ple injuries. This scoring s y s t e m has been used w i d e l y in the s t u d y of t r a u m a because it is reproducible and highly predictive of mortality. 3 ISS is a n u m e r i c a l m e a s u r e of ana t o m i c injury in body regions and allows the c o m p a r i s o n of injury severity and o u t c o m e in different p a t i e n t populations. The ISS m a k e s possible the s t u d y of t r a u m a interventions by controlling for the severity of injury in groups r e c e i v i n g care different from c o n t r o l groups. Few h a v e argued t h a t the ISS fully characterizes trauma, even in the p r e d i c t i o n of m o r t a l i t y . A d d i t i o n of a d e t e r m i n a t i o n of physiologic d e r a n g e m e n t (the T r a u m a Score) 4 and p a t i e n t age r e s u l t s in a m e a s u r e m e n t w i t h m a r k e d l y i m p r o v e d ability to quantify the probability of survival. 1 However, the ISS and related t r a u m a scales do n o t categorize t r a u m a patients on the basis of resources required for their care. See related article, p 1396. Baxt and U p e n i e k s have developed a definition of major t r a u m a m o r e closely related to the resources required to care for injured patients in their institution. Thus, it is not surprising that the ISS does n o t segregate p a t i e n t s into major and m i n o r categories based on this n e w definition. We are r e m i n d e d that planning for the care of the t r a u m a p a t i e n t r e q u i r e s k n o w l e d g e of t h e c a p a b i l i t i e s t h a t a t r a u m a facility m u s t m a i n t a i n in order to o p t i m a l l y treat the i n j u r e d p a t i e n t . F r o m this s t a n d p o i n t , e v a l u a t i o n of Baxt and U p e n i e k s ' d e f i n i t i o n of m a j o r t r a u m a by the T h e r a p e u t i c I n t e r v e n t i o n Score, 5 a m e t h o d of e x p l i c i t l y
19:12 December 1990
m e a s u r i n g m e d i c a l r e s o u r c e use, w o u l d be i n f o r m a t i v e . Such an operational definition of trauma, due to its subjective e l e m e n t s (eg, the definition of positive operative findings as " t r a u m a t i c injuries that could have been lifethreatening"), is less u s e f u l in c o m p a r i n g o u t c o m e s of t r a u m a care in different p a t i e n t populations. Thus, n e i t h e r the ISS nor the operational definition of major t r a u m a proposed by Baxt can be said to fully characterize major trauma. Rather, the approaches to the evaluation of t r a u m a care represented by both are c o m p l e m e n t a r y and n e c e s s a r y to t h e c o m p l e t e u n d e r s t a n d i n g of trauma. Terence D Va]enzuela, MD, FACEP, FACP Section of Emergency M e d i c i n e D e p a r t m e n t of Surgery University of Arizona College of Medicine Tucson 1. Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: The TRISS method. J Trauma 1987;27:370-378. 2. Baker SP, O'Neill B, Haddon W, et ah The injury severity score: A method for describing patients with multiple injuries and evaluating emerk gency care. J Trauma 1974;1&187-196. 3. Copes WS, Champion HR, Sacco WJ, et ah The injury severity score revisited. J Trauma 1988;28:69-77. 4. Champion HR, Sacco WJ, Camazzo AJ, et ah The trauma score. Crit Care Med 1981;9:672-676. 5. Keene AR, Cullen DJ: Therapeutic intervention scoring system: Update 1983. Grit Care Med 1983;11:1-3.
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