Whether Washington should have more high level trauma hospitals, and where to put them, are questions the state Department of Health is hoping to have answers for soon.
Washington’s trauma system is more than three decades old, and is designed to deliver the right patient to the appropriate facility in an adequate amount of time. In 1990, the Trauma Care Systems Act outlined recommendations from studies and created five levels of adult, and three levels of pediatric trauma care services. The system was designed to unify the state’s trauma centers into a single network to better serve patients.
It’s a system that has worked well. More than 80% of the state’s population has access to the top two levels of trauma care within one hour by either air or ground transportation, and roughly 98% of the state can access at least a level 3 center within the same amount of time, said Dr. Eileen Bulger, chief of trauma for Harborview Medical Center.
Currently, there’s only one level 1 hospital — Harborview Medical Center — in Washington state, along with six level 2 hospitals, and many more lower level facilities statewide. But level 1 and 2 hospitals, which provide the most robust and specialized care services, are concentrated in western Washington. There’s a single level 2 hospital east of the Cascades, in Spokane.
At a regional level, Harborview is the only level 1 facility not only in Washington, but in Alaska, Idaho and Montana. Other hospitals in the region will transfer patients to Harborview when they need highly specialized or complex care.
Both level 1 and 2 centers are nearly equal in their ability to treat severe trauma. The key difference is level 1 facilities theorized to be teaching hospitals with a high volume of patients. Level 2 centers are expected to provide the same level of care for most patients, not including highly specialized services, according to the Department of Health.
Level 3 centers, and those with lower ratings, serve as entry points into the trauma system where patients are stabilized before they are transferred to higher trauma centers if needed. In 2019, there were 82 acute care facilities in the state that participated in the trauma system. There were also about 20 acute care facilities that aren’t part of the state’s trauma system, mostly located in the Seattle area.
But access to higher levels of care isn’t uniform across the state.
Much of the population that can’t reach a level 2 facility within an hour lives in Central Washington. Wenatchee’s Central Washington Hospital was a level 2 center until 2007, when the state downgraded it to a level 3. At the time, the hospital stated a lack of neurosurgeons was to blame. Bulger said:
There’s definitely a gap in the center of the state where we would love to have a level 2 facility.”
A state report found that the addition of a level 2 center in Yakima would lead to an increase in population coverage of 260,000 people. Some 182 trauma cases occurred within the estimated coverage area of a level 2 Yakima center. A similar center in Wenatchee would increase coverage by about 88,000 residents, accounting for 926 trauma cases, the report said.
But it’s not clear if hospitals are interested in or able to take on the significant costs required to provide expanded care.
In an email, Yakima Valley Memorial Hospital’s Chief Medical Officer, Dr. Marty Brueggemann said the hospital has no plans to seek level 2 designation. The facility is currently a level 3 hospital.
“A level 2 trauma center requires a number of things that we don’t provide here, including neurosurgery and thoracic surgery programs, just to name a couple,” Brueggemann wrote. “There are also requirements for response times and availability that would require changes to models of care that are not practical for us (for example your general surgeons cannot engage in non-trauma work while on call for trauma and need to be immediately available). Pursuing this would be a multi-million dollar investment with little financial or strategic incentive.”
Katie Pope, spokesperson for the state Department of Health said they haven’t received requests from hospitals seeking level 2 designation since 2014. And there have been no level 1 service requests since the trauma system was created and Harborview designated as the sole level 1 hospital.
The state has also explored whether an additional level 1 hospital would be useful. A 2019 report to the Department of Health, conducted by the American College of Surgeons Committee on Trauma, found that enhancing clinical services at level 2 centers in eastern or southwestern Washington would improve care for citizens, and may fulfill state requirements for level 1 designation.
At an operation level, a second level 1 hospital in eastern Washington wouldn’t impact clinical operations at Harborview. However, it would impact Harborview’s financial model, leading to fewer patients being treated at the hospital, and a reduced ability to pay the bills associated with the designation. “That said, there is no clear clinical need for additional level 1 resources per se, based on the minimal differences between criteria for level 1 and level 2 centers, and the intended clinical equivalence (between them),” the report states.
Still, the state is conducting a rulemaking process to understand and develop what requirements it should apply for hospitals to become a level 2 trauma center, and how a growing population in Washington may require additional centers. Since the trauma system was created, there hasn’t been a review of the process or criteria for trauma care regions and the department for making center distribution decisions.
Pope said the department is focused on ensuring the trauma system works for all communities, with attention paid to underserved and rural communities.
“In addition to thinking about health equity from a patient perspective, we are also focused on equity in terms of a patient’s family or communities’ ability to support them once they are in a hospital,” Pope wrote. “Requiring family members to travel great distances and spend money on travel and lodging creates further barriers to care and healing, particularly for underserved and rural communities.”
Bulger said the Department of Health is expected to move into rulemaking in January, collaborating with experts throughout the state to develop criteria for hospitals and trauma care facilities seeking higher designations.