Save Our Emergency Rooms

Gulf Coast Trauma Planning Task Force
Final Report
August 26, 2002
Click here for PDF version for printing.

Executive Summary
The Problem
As reported in the Houston Chronicle in March 2001, both of Houston's Level I trauma centers, both children's hospitals and several of Houston's five Level III hospitals outside the Texas Medical Center declared divert status simultaneously. As a result, at least one child was transferred to Temple, Texas, for care and subsequently died.

On Halloween night, 2001, a 21-year old man sustained serious head, chest and leg injuries when he was struck by a car in Katy. As chance had it, all of Houston's trauma care facilities were full. Although he was medically unstable, the man was flown some four hours after sustaining his injury to Brackenridge Hospital in Austin, where he died the next day.

In February 2002, two patients died in the emergency room of a rural hospital in the Houston - Galveston Region after the hospital tried unsuccessfully for six hours to transfer the patients to a major trauma center. At least one of these deaths was probably preventable.

The emergency and trauma care system in the Houston-Galveston region is deteriorating. Overcrowded emergency departments and full intensive care units are becoming the norm, which results in area hospitals closing their doors to new, sometimes seriously injured and ill patients-a situation called "diversion." The number of hours that area hospitals were "on diversion" increased by 77 percent in the last year. Diversion negatively affects all residents, regardless of income or health insurance status.

In addition, the events of September 11, 2001, have put new emphasis on homeland security and local preparedness in the event of a terrorist attack or other mass casualty event. Unfortunately, our trauma and emergency services system is so stressed under normal circumstances that it almost certainly will break under the substantial load of a mass casualty event.

In response to these pressures, a Gulf Coast Trauma Planning Task Force consisting of local medical professionals, community leaders, and business leaders was convened. The Task Force analyzed this problem from late spring through summer 2002 to identify the sources of the problem and recommend solutions. The Task Force concluded that without additional funding and resources for the treatment of uninsured emergency/trauma patients, there could be no expansion of services in the Houston-Galveston region. Coupled with regional planning and coordination, it is more likely that increased funding will be necessary for the expansion of trauma capacity.

The Vision
The vision adopted by the Task Force is the creation of a coordinated, fully maintained metropolitan trauma response system that provides access to a designated trauma facility for every person within one hour of a trauma incident.

The Solutions
The Gulf Coast Trauma Planning Task Force developed four major recommendations to address the crisis in our emergency departments in the short term and achieve the vision. Each of the following is discussed in detail in the full report:

1. Increase Funding for Uncompensated Emergency/Trauma Care
2. Improve Coordination and Accountability of Emergency Services in the Region
3. Increase Local Trauma Center Capacity
4. Improve Local Injury Prevention Efforts

The Task Force also recognized and made recommendations that address broader issues with the health care delivery system that contribute to the crisis in local emergency centers. These recommendations, which are discussed in detail in the full report, address the high percentage of uninsured Texans, limited availability and knowledge of non-emergency department resources, rising medical malpractice premiums, and health care workforce shortages.

Implementation
To coordinate and monitor the implementation of its recommendations, the Task Force recommends the creation of an Emergency/Trauma System Implementation Task Force composed initially of representatives from governmental and non-governmental entities in Harris County, then expanding over time to include representatives from around the 13-county Houston-Galveston region.

Introduction: A System in Crisis
Over the last several years, providers of emergency and trauma care in the Houston-Galveston region, have been placed under increased pressure in treating seriously ill and injured patients. Demand for these services has continued to increase, frequently outstripping these providers' capacity to provide care. With overcrowded emergency departments and full intensive care units, too often resources have not been available to care for seriously injured patients or to accept patients transferred from small hospitals that are unable to provide the required level of care.

Placing additional pressure on the emergency and trauma care system are the events of September 11, 2001. In the wake of these events, national, state and community leaders, both elected and non-elected, have prioritized the issue of homeland security preparedness in the event of a terrorist attack or other mass casualty event. An efficient, coordinated emergency and trauma care system is an integral part of our community's preparedness for any event that threatens our homeland security.

Studies recently commissioned by Save Our ERs have quantified that the emergency and trauma system in our area is deteriorating. A survey of hospital emergency departments across the region conducted by The Abaris Group indicated that hospital diversion hours increased by 77 percent from 2000 to 2001. Furthermore, 69 percent of emergency departments reported that it takes three hours or more to transfer seriously injured patients to facilities that provide a higher level of care. Both of these situations result in negative health outcomes for area residents in need of emergency care.

The results of a study conducted by Bishop+Associates of the region's trauma facilities are even more sobering. Bishop+Associates notes that while trauma systems nationally are experiencing economic pressure, the Houston-Galveston regional trauma system in particular is in serious jeopardy because the proportion of uninsured trauma patients is double the national norm. Those hospitals providing the highest level of care to seriously injured patients indicated they could not accept all transfers due to high trauma caseloads and high ICU occupancy levels. Very high trauma patient volumes in relation to hospital capacity have negatively impacted other programs at these hospitals as well. The Bishop+Associates report urges that corrective action be taken in the near term to avert trauma system collapse.

In response to these pressures, a Gulf Coast Trauma Planning Task Force consisting of local medical professionals, community leaders, and business leaders was convened. The Task Force met on a regular basis from late spring through the summer of 2002 to review issues and recommend responses to the growing emergency and trauma capacity crisis in our area. This report details the process undertaken by the Task Force, the proposed recommendations of the Task Force, and a suggested path for future action.

Process: Vision, Region, Research
The first task of the Task Force was to develop a vision of what the ideal Houston-Galveston area trauma response system should be. The following vision was agreed upon: "A coordinated, fully maintained metropolitan trauma response system that provides access to a designated trauma facility for every person within one hour of a trauma incident."

The second task of the Task Force was to identify the region in which the model metropolitan trauma response system will operate. The Task Force considered several regional groupings: the eight-county Houston-Galveston-Brazoria Consolidated Metropolitan Statistical Area, which includes Harris and seven contiguous counties; the Houston-Galveston Area Council, which includes Harris and 12 other counties; and the 18 counties that comprise Trauma Service Areas Q and R (see Attachments A and B for maps of these areas). The Task Force agreed to use the second option: the 13-county region that composes the Houston-Galveston Area Council. The total population of the 13-county region, according to the 2000 census, is 4,854,454 (see Attachment C for a chart of population figures for each of the 13 counties and Attachment D for a map of these counties).

The third task of the Task Force was to review all of the facets of the existing trauma response system, identify problems and concerns, and develop recommended solutions. These recommendations are presented in the next section.

Recommendations
The Task Force divided its recommendations into two major groups: (1) those that address specific trauma and emergency services delivery issues identified by the Task Force; and (2) those that address broader health care delivery system issues that exacerbate the crisis in our local emergency departments.

Important Note: Because of the complex nature of the health care delivery system, the following recommendations are highly interrelated and interdependent. Each recommendation should be considered in terms of its direct effect, its effect on other recommendations, and its ripple effect on the health care system as a whole.

Trauma and Emergency Services
The following recommendations relate specifically to trauma and emergency services. They include asking the Legislature for direct funding for uncompensated emergency care, improving the delivery of emergency services, improving coordination and accountability of the trauma response system, increasing the capacity of the trauma system, and establishing regional injury prevention centers. These recommendations also will enhance the Houston-Galveston region's ability to maintain a heightened level of preparedness in the event of a terrorist attack or other mass casualty event.

1. Increase Funding for Uncompensated Emergency/Trauma Care
The large and increasing amount of uncompensated health care delivered in emergency departments places tremendous financial pressure on area hospitals and forces these hospitals to go on diversion status more often, which threatens all area residents' access to emergency services. According to Bishop+Associates, hospitals providing trauma in the Houston trauma system in 2001 recorded overall financial losses of $19.7 million and spent over $33.5 million to provide trauma services to the uninsured. These losses are a result of a proportion of uninsured patients that is double the national norm, a very high transfer rate of low severity injury patients to Level I trauma centers, and severe capacity constraints.

The Texas Legislature in 1999 created a state account called the Tertiary Care Account, into which it directed unclaimed lottery prize money in the amount of $16 million for the biennium. All licensed trauma facilities in the state can receive annual disbursements from this account in proportion to the amount of uncompensated trauma care they provided to individuals who reside outside of the county in which the facility is located. Because of the significant amount of uncompensated out-of-county care that is provided in the state, and the relatively small size of the account, these disbursements typically amount to pennies on the dollar.

Recommendation: Ask the Legislature to appropriate additional funding from a stable funding source to the state Tertiary Care Account. Also, ask the Legislature to expand the use of the account to allow hospitals to be reimbursed for all uncompensated care delivered in the emergency setting (rather than just for trauma care delivered to out-of-county residents).

2. Improve Coordination and Accountability of Emergency Services in the Region
The Task Force agreed that a key component of a coordinated, fully maintained metropolitan trauma response system is improved coordination and accountability of emergency medical services (EMS) and other first responders. A coordinated and accountable EMS/first responder system will ensure that trauma services are delivered in the most effective and efficient way; it also will ensure that the Houston-Galveston region is prepared for a terrorist attack or other mass casualty event.

The Task Force also agreed that the Houston-Galveston region needs a formalized structure to accomplish the goals of regional planning, coordination and accountability of EMS and trauma services. One structure that could be used is the existing local EMS and Trauma Regional Advisory Councils (RACs). Alternatively, an entity such as the Houston-Galveston Area Council (H-GAC) could be used.

Recommendation: Identify a properly constituted regional entity that would have the responsibility and necessary authority for regional planning, infrastructure development and ongoing coordination of emergency services and trauma care.

One of the limitations of the current RAC structure is their limited capability to ensure accountability. For example, participation in the RAC is required of all licensed hospitals that operate a Level I, II, III, and IV trauma center, but EMS provider participation is optional.

Recommendation: Support legislation to require any EMS provider that responds to calls from the public for emergency service and any hospital that intends to receive such patients from EMS providers to participate in the selected regional planning entity as a requirement of licensure in the State of Texas.

The Task Force also identified a need to develop coordinated transportation plans that ensure appropriate patient transport within the Houston-Galveston region by EMS providers to the appropriate medical facility based upon injury severity. This will ensure a rational distribution of patient loads throughout the system. There also is a need for consistent monitoring of the quality of delivery of emergency services in the region.

Recommendation: The selected regional planning entity should:

Establish protocols to ensure that low severity emergency and trauma patients are delivered to Level III facilities when appropriate, reserving capacity at the Level I facilities for more critically injured patients;
Assess state legislative options and local ordinance options regarding the limitation of patient facility choice when it is in the best interest of efficient and effective patient care; and
Conduct data collection and monitoring of the quality of emergency services in the Houston-Galveston region, including for example hospital diversion rates, EMS transport times, ability of smaller trauma facilities to transfer to larger trauma facilities, and number and type of patients endangered because of diversion, lengthy transport or transfer times.

Coordination of emergency services and trauma care for the Houston-Galveston region also could be improved through the use of inter-local agreements between public entities, private entities and political subdivisions across the multi-county region. Inter-local agreements are formal contracts between two entities that specify the way in which the entities will cooperate to perform certain functions. Through these agreements, guidelines could be established that coordinate emergency medical response and the delivery of patients requiring emergency care.

There is a precedent for these types of agreements. For example, discussions already are underway in the area of shared communication systems among first responders in the Houston-Galveston region. Discussions also are underway to negotiate inter-local mutual aid agreements that support regional plans and responses to terrorist attacks or other mass casualty events. In fact, these agreements are required to receive grants for first responder preparedness from the federal government.

Recommendation: Support the creation of an EMS Workgroup, affiliated with the selected regional planning entity and chaired by the City of Houston EMS Director, charged with facilitating coordination of all emergency medical services - at first countywide and subsequently region-wide. This would include the development of appropriate inter-local agreements.

These inter-local agreements would help establish a base of trust between governmental entities in the Houston-Galveston region on a health care related issue and could potentially serve as the basis for future inter-local agreements relating to structure and finance of the coordinated, fully maintained metropolitan trauma response system envisioned by the Task Force.

3. Increase Local Trauma Center Capacity
The standard the Task Force used to project the need for additional trauma care facilities in the area was the benchmark of the American College of Surgeons: There should be a Level I or II trauma center in a metropolitan area for each one million residents. Using this standard, there should be five for the Houston-Galveston region, and based on projected population growth in the region a sixth Level I or II facility should be planned. The region now has three Level I trauma centers (see Attachment D). Two are in Houston-Memorial Hermann and Ben Taub-and one is in Galveston-UTMB. There is no Level II center; however, there are eight Level III centers and nine Level IVs in the region. Note that Level I and II trauma centers are required to provide the same spectrum of care to injured patients; the only difference between the two levels is that Level I facilities conduct research and Level II facilities do not.

The Task Force developed the following options relating to additional trauma center capacity. Important Note: The following list was developed by the Task Force for discussion purposes only. None of the following entities have committed in any formal way to pursue these options at this time. It also is important to note that the following options assume the preservation of all existing Level I trauma centers in the Houston-Galveston region, which is not a certainty without direct, stopgap funding from the Legislature through the Tertiary Care Account recommendation found on page 6.

Harris County Hospital District expansion. Upgrade the Harris County Hospital District's LBJ Hospital from a Level III trauma center to a Level II/Level I trauma center. This could add up to 150 new beds to LBJ Hospital, including new ICU beds that would help alleviate the ICU bed shortage. In addition, construct a new 250-bed HCHD hospital somewhere in the county that could perform elective surgery and function as a Level III trauma center. This new facility would help offload patients from existing Level I trauma centers and ensure that these facilities could remain dedicated to serving the community's most severe trauma cases.

CHRISTUS St. Joseph's Hospital expansion. Upgrade CHRISTUS St. Joseph Hospital from a Level III trauma center to a Level II trauma center. Funding will be a critical element in moving forward with plans to expand services at CHRISTUS. Given the capital requirements and the operating losses, to support ongoing operations, funding will be required on an on-going basis. Suggestions for funding include a community capital campaign to fund both the start-up and continuing operating expenses, funding indigent patients through the Texas Medicaid program, and other funding sources. In addition, any expansion effort would be subject to the receipt of a favorable response from the CHRISTUS medical staff and the CHRISTUS Gulf Coast Regional Board.

Memorial Hermann Healthcare System expansion. Upgrade Memorial Hermann Southwest Hospital from a Level III trauma center to a Level II trauma center, while maintaining Memorial Hermann Hospital as a Level I trauma center. Any expansion efforts by the Memorial Hermann Healthcare System would face similar challenges and concerns (e.g. funding, medical staff, board approval) as the CHRISTUS St. Joseph Hospital expansion option described above.

Creation of a Single Level I Trauma Facility for the region. Centralize Level I trauma services at a Texas Medical Center site to be determined. The concept of a "super" trauma center that only handles the most seriously injured and ill patients has been successfully implemented in several sites around the country. This recommendation was first proposed for the Houston-Galveston region over 20 years ago and has been considered in several venues ever since. For example, in the Harris County Medical Society's November 1, 1990 Trauma Care Commission report, it was recommended that the Medical Society should proceed with a feasibility study to determine the size requirements and capital needs for construction or acquisition of, and the operational funding to maintain, a healthcare facility dedicated solely to the care and treatment of major trauma victims in the Southeast Texas region.

There are several ancillary issues to the development of additional trauma center capacity, the most acute of which is how to achieve the coverage of specialists that is required for certification as a Level I or II trauma center. Local medical schools currently provide the coverage for the existing Level I trauma centers, however, their limited resources already are stretched thin and therefore any expansion of their responsibilities would certainly require additional resources. One potential alternative that was discussed by the Task Force would be to retain a private-sector medical staffing firm. In this scenario, the trauma center would pay the firm, and the firm would pay the specialists on a salary basis for a fixed number of days of coverage per week and handle all administrative duties for the specialists. This is just an example; whatever the route pursued, the important point is that physician coverage will be a significant issue with any trauma center expansion.

Recommendation: Explore the feasibility of options to expand trauma capacity including, but not limited to, those outlined above.

4. Improve Injury Prevention Efforts
Injuries are expensive and put a preventable strain on our healthcare system. Each year about 2.6 million Americans are hospitalized for injuries, about 39.6 million people are treated in hospital emergency departments, and about 60.5 million people seek medical attention or suffer at least a day of activity restriction from an injury. The economic impact for fatal and nonfatal injuries in this country exceeds $260 billion a year. Unintentional injuries account for about two-thirds of those costs.

Injury prevention centers (IPCs) help reduce the incidence and severity of injuries through education, public information, data collection, community advocacy and research. IPCs promote intervention strategies that work - for example, promoting the use of child safety seats (which reduce the risk of death and serious injury by 70 percent), promoting the use of seat belts, and discouraging drinking and driving. There are several well-developed IPCs in the Houston-Galveston region, for example at Texas Children's Hospital, but they need to be augmented and supported financially by the state to strengthen their messages of prevention.

Recommendation: Endorse the creation of a new IPC that would coordinate with existing injury prevention programs in the Houston-Galveston region under the leadership of Dr. James "Red" Duke. The IPC would develop new injury prevention initiatives throughout the region to address areas such as motor vehicle injuries, violence, falls, burns/scalds, poisonings, occupational injuries and recreational injuries.

Recommendation: Support efforts to secure funding from the Legislature for regional injury prevention centers around the state and to pass any necessary authorizing legislation.

Health Care Delivery System
The above recommendations address specific trauma and emergency services-related issues, but they do not address the underlying and broader problems within the health care delivery system that also contribute to the crisis in local emergency departments. These issues include the high percentage of uninsured Texans, limited availability and knowledge of non-emergency department resources, rising medical malpractice premiums, and health care workforce shortages, for example.

1. Increase the Number of Insured
An estimated 1.1 million residents of the 13-county region do not have health insurance coverage. In Harris County alone over 700,000 individuals do not have health insurance. Because of its sheer size and diversity, developing global solutions to link this group to health insurance coverage is a very complex undertaking. A more manageable approach is to subdivide this group into several subgroups using factors such as income and family composition, develop solutions for each group, and then amalgamate those solutions into an overall plan to increase the number of people with health insurance coverage.

The benefits to the regional trauma response system of increasing the number of people with health insurance coverage include:

Changing the market incentives around trauma care by creating some form of reimbursement for currently uncompensated care;
Reducing emergency department usage for non-emergent health care needs by linking uninsured individuals with primary care providers and the means to pay for visits to those providers;
Encouraging preventive care-numerous studies demonstrate that people without insurance delay needed care and allow conditions that could have been treated earlier to deteriorate-and reducing the overall burden on the system by creating a healthier patient base;
Spreading the benefit of a new financial investment by the federal government throughout the system, including not just trauma centers but also physicians and other providers, who would be compensated for previously uncompensated care; and
Encouraging stability in the system by making the utilization of health care services by the uninsured population more predictable and regular, like that of the insured population.

Recommendation: Encourage the Legislature to pursue a series of sequential initiatives to link the uninsured residents of the region with health insurance coverage. These initiatives should leverage multiple sources of funding, including existing local dollars, individual contributions, new state dollars, new federal dollars, and employer contributions where possible and appropriate.

For example, state Senator Jon Lindsay and his staff are researching an initiative to use new federal flexibility to create Medicaid-level coverage for uninsured parents with incomes below the federal poverty line, financed by local dollars, federal dollars and individual contributions. This initiative could leverage $110 million in existing local funding to provide coverage to as many as 110,000 uninsured parents in the 13-county Houston-Galveston region, while also bringing in $160 million in new federal dollars to the system. The Task Force supports this and other legislative initiatives to reduce the number of uninsured in the region.

2. Improve Access to Non-Emergency Health Care Services
By some estimates, as many as half of the total visits by residents to area emergency departments are for conditions that are not emergencies and that could have been treated in alternative settings. The presence of large numbers of residents with non-emergency conditions in area emergency departments is a problem for two reasons:

Emergency department care is the most expensive kind of care, with a simple screening costing three times as much in an emergency department setting as in a non-emergency department setting; and
Individuals with non-emergency conditions require the use of scarce emergency department resources, especially staff time, which causes hospitals to go on diversion status sooner and more often. A related problem is the number of patients served in emergency departments for conditions that, if treated earlier, would not have been emergencies. The Task Force agreed that both problems stem from (1) a lack of available alternatives for non-emergency care; (2) lack of knowledge in the population about those resources that are available for non-emergency care; and (3) community misconceptions regarding access.

Lack of available alternatives for non-emergency care. Local medical professionals estimate that on average, each individual requires about three non-emergency physician visits per year. With over 700,000 uninsured individuals in Harris County alone, we would hope to see approximately 2.1 million outpatient visits for the uninsured alone. In the Harris County Hospital District, outpatient physician visits (not including emergency departments) total less than 750,000 per year. While there are undoubtedly uninsured patients seen in other public facilities as well as in private clinics and physician offices, HCHD data suggests that uninsured access to clinics is markedly below reasonable standards. High emergency department usage is one outcome of the clinic deficiency.

Fortunately, there have been recent efforts on a community-wide basis through the Harris County Gateway to Care to address the shortage of adequate access points for the uninsured. The following recommendations reflect many activities that are already underway in both the private and public sectors.

Recommendation: Support Harris County Gateway to Care efforts to redesign existing clinic systems to improve the efficiency of existing clinic resources, improve patient satisfaction, and increase capacity by up to 10 percent.

Recommendation: Support Harris County Gateway to Care efforts to expand primary care clinic hours and days of operation. Also, explore the possibility of providing psychiatric services at primary care clinics.

Currently, many physicians and hospitals in the Houston-Galveston region provide charity care to the uninsured and underinsured. The use of these charity resources by patients, however, is irregular and uncoordinated, which can result in providers becoming frustrated and ceasing to provide charity care. To address this problem and maximize the use of these resources, the Harris County Gateway to Care is developing a Provider Health Network in which each provider would be asked to provide a fixed amount of charity care "slots" for uninsured patients. Harris County Gateway to Care, through the use of an information system, will serve as a centralized referral entity and refer uninsured patients to providers in the network.

Recommendation: Support Harris County Gateway to Care efforts to create a Provider Health Network that will engage 2,000 providers and 10 hospitals in a network to provide charity health care to a minimum of 24,000 patients in three years.

Clinics that meet certain requirements of federal law can be designated as federally qualified health centers (FQHCs). The benefits of FQHC designation include access to annual grant funding from the federal government (e.g. Galveston County Community Care Clinic receives $1.6 million annually), enhanced reimbursement under Medicaid and Medicare, and access to low-rate capital financing. Harris County currently only has one FQHC, South Central Community Health Center.

Recommendation: Support Harris County Gateway to Care efforts to increase the number of federally qualified health centers (FQHCs) in Harris County from one to 11. Additional FQHCs would pull additional federal funds into Harris County for the provision of primary health care.

Urgent care facilities have flourished in recent years to provide an alternative to the emergency department for patients who have health problems that are not considered to be emergencies (e.g. sore throat, sprained ankle) but who do not want to wait for an appointment at a clinic or a doctor's office. St. Luke's Episcopal Health System, for example, operates the St. Luke's Urgent Care Center on Holcombe Drive for these types of patients. Another example would be the new 250-bed HCHD hospital discussed above (see "Increase Local Trauma Capacity" section).

Some of these facilities operate on a cash basis only, where services are provided on a drop-in basis with payment expected at the time of service. Memorial Hermann Healthcare System is exploring this concept for a new facility in southwest Houston.

Recommendation: Support efforts to expand the availability of urgent care facilities.

Recommendation: Explore the possibility of creating "cash clinics" in which there are no appointments or financial eligibility determination.

Under the 1996 federal welfare reform legislation, public hospitals are prohibited from providing care to immigrants outside of the emergency department on a discounted basis without regards to their immigration status. Giving local units of government the flexibility to care for these populations, on local option basis, in the appropriate settings will decongest our emergency departments, increase public health outcomes, and minimize costs to local taxpayers. In 2001, the Harris County Hospital District provided $18.8 million worth of primary and preventive health care services to undocumented immigrants in an outpatient setting. Directing this volume through the emergency departments would triple its average cost and place significant additional pressure on the already frail system.

Recommendation: Ask the Legislature to allow public hospitals in Texas to provide primary and preventive care to immigrants in the outpatient setting without regard to immigration status.

Knowledge of community services and resources. Language, culture, negative healthcare experiences, and isolation are often barriers to obtaining information about healthcare services and resources. Supportive services are required to enable community members to effectively access care.

Recommendation: Consider expanding the telephone nurse triage system that is being piloted at the Harris County Hospital District to 24 hours a day, seven days a week. This system, which educates callers on methods of accessing healthcare services and reduces inappropriate use of the emergency center, currently only operates from 4 p.m. to 11 p.m., seven days a week. Also, consider conducting a community awareness campaign to promote the use of this service.

Language and cultural barriers oftentimes inhibit uninsured patients from accessing the health care system in an effective and efficient manner. Community health workers, also called "Navigators," are members of particular communities that help educate fellow members of that community on the availability of health care resources and the appropriate use of those resources (e.g. keeping health care appointments).

Recommendation: Support Harris County Gateway to Care efforts to expand the availability of navigation services.

Community misconceptions regarding access. There are a myriad of beliefs across all populations that the emergency center is the appropriate place to seek medical care, despite the acuity of the illness or injury. Populations have beliefs that emergency care is quicker, better, easier to access, and comparable in costs. The uninsured and underinsured are high users of emergency care because they perceive barriers to accessing primary care.

Recommendation: The Harris County Hospital District should consider conducting ongoing analysis of emergency department visits to derive populations and diagnostic categories to be targeted in community outreach and education programs, with the goal of reducing inappropriate emergency center use.

Recommendation: Provide information to the community regarding methods of effectively utilizing health care services, including proper preparation for an initial appointment and the location of community-based clinics. Report to the community the utilization of the health care system and successes in improving access.

3. Seek Federal Support for the System
Through its research, the Task Force identified a variety of issues for which federal government support and action would be helpful.

Recommendation: Communicate to Congress the importance of:

Developing a long-term federal solution to the problem of the uninsured;
Maintaining funding for successful community-based initiatives, like Harris County Gateway to Care, that seek to improve access to health care for the uninsured by coordinating existing resources;
Maintaining funding for federally qualified community health centers (FQHCs);
Providing federal financial support for the cost of providing health care to immigrants; and
Providing adequate federal resources to the Medicaid Disproportionate Share Hospital (DSH) program and other federal health care funding streams (e.g. Upper Payment Limit arrangements) that help subsidize the cost of providing health care to the uninsured and keep hospital doors open.

4. Address Rising Medical Malpractice Premiums
Another problem identified by the Task Force that is plaguing local emergency departments is the increasing number of physicians, especially specialists like neurosurgeons, who refuse to "take call" (that is, be on call in the case of an emergency) in trauma centers because of the increased risk of medical malpractice lawsuits and rising medical malpractice insurance rates. This problem is of particular importance in light of the Task Force's recommendations to expand the capacity of the trauma system; without malpractice reform it will be increasingly difficult to recruit new physicians to the Houston-Galveston region to serve the expanded trauma system.

Recommendation: Support legislative efforts to reduce the cost of medical malpractice insurance, for example those of the Texas Alliance for Patient Access, which includes in its membership the Texas Hospital Association and the Texas Medical Association.

5. Reduce Health Workforce Shortages
The Task Force identified health workforce shortages as one of the broader issues affecting the delivery of trauma services in the Houston-Galveston region. State efforts to address this issue have been led by a coalition of the Texas Hospital Association and the Texas Nurses Association. Their efforts have been augmented by the work of local groups such as the Greater Houston Partnership and the Texas Medical Center.

Recommendation: Support the efforts of the Texas Hospital Association, the Texas Nurses Association, and the special committees of the Greater Houston Partnership and the Texas Medical Center to address the shortage of nurses and other non-physician health care practitioners. These efforts include:

Funding to increase the capacity of Texas nursing programs to double the number of nursing school graduates by 2008;
Funding to increase nursing faculty salaries and benefits;
Funding to increase student financial aid for students in non-physician health care career fields;
Creation of a special state fund to demonstrate and test innovative approaches for recruiting and retention of nurses; and
Allowing non-state-resident students in nursing and other non-physician health care career fields to pay in-state tuition and fees.

In addition to local and state efforts, national organizations such as the American Hospital Association and the American Nurses Association are working on federal solutions to address health workforce shortages. Recently, Congress passed and President Bush signed the Nurse Reinvestment Act of 2002 to address the nursing shortage, but additional action is necessary.

The Accrediting Council for Graduate Medical Education (ACGME), supported by the American Medical Association, established regulations effective July 1, 2003, which require medical residents, fellows and interns to abide by new work hour rules. These new rules restrict the time and hours in which a house staff may work in a teaching hospital. This will put additional strain on the existing Level I and III trauma centers in the Houston-Galveston region for medical staffing. It will also increase the financial commitment of these institutions to continue to provide emergency/trauma care. In New York State the additional cost to teaching hospitals was in excess of $200 million.

Recommendation: Ask Congress to support:

Full funding for the Nurse Reinvestment Act of 2002;
Modification of immigration and visa laws to make it easier to recruit and retain foreign non-physician health care workers as a short-term solution, particularly in the area of nursing;
Increasing federal loan repayment programs for physicians and non-physician health care workers who work for five years in a Level I, II or III trauma center; and
Increasing federal graduate medical education payments to Level I, II and III trauma centers to offset the increased cost of physician staffing due to new hourly caps on the workload of resident physicians.

Implementation: Forming a New System
The above recommendations provide a starting point for the creation of "a coordinated, fully maintained metropolitan trauma response system that provides access to a designated trauma facility for every person within one hour of a trauma incident." Much hard work lies ahead by all participants in the system to make this long-term vision of the Gulf Coast Trauma Planning Task Force a reality.

The Gulf Coast Trauma Planning Task Force envisions implementation beginning with a focus on Harris and Galveston County, then expanding to the rest of the region over time. To coordinate and monitor the implementation of the above recommendations, the Task Force suggests the creation of an Emergency/Trauma System Implementation Task Force composed initially of representatives from Harris County, Harris County Hospital District, University of Texas Medical Branch at Galveston, Memorial Hermann Healthcare System, CHRISTUS Health, St. Luke's Episcopal Health System, Hospital Corporation of America, Texas Children's Hospital, Methodist Hospital and the City of Houston EMS, and other members as appropriate. This Task Force would be staffed with existing resources of the member organizations. It would meet regularly, coordinate and monitor the implementation of the recommendations, provide regular progress reports, and make additional recommendations when necessary for consideration by the member organizations to improve the trauma response system.

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