Indiana’s trauma care system falls short in rural counties; will money in the budget be enough?
WINAMAC, Ind. — When it’s time to move a patient from this town’s six-bed emergency room to a larger hospital specializing in trauma care, Brandon DeLorenzo sometimes has to wait.
The Pulaski County emergency medical services director can typically spare one of his two ambulances to make the 1 hour and 15-minute drive to the nearest trauma centers in Lafayette or South Bend.
But occasionally when a medic takes a vacation, DeLorenzo is down to one truck — and he’s forced to keep it available for a potential vehicle crash or other emergency somewhere across the 435 square miles of mostly farmland.
So trauma patients wait at Pulaski Memorial Hospital for sometimes hours.
“Our primary focus is 911. We can’t take that truck out of the county,” said DeLorenzo, who serves as a paramedic on one of the ambulances when he is on the clock. “There’s really nothing we can do.”
While hospitals across Indiana handle many types of injuries just fine each day, severe injuries require greater attention from doctors and staff at a trauma center.
In trauma care, time is everything. Minutes matter.
The problem? Indiana’s 24 trauma centers are primarily clumped around big cities while nearly 1 in 10 Hoosiers live more than 45 minutes away from one.
Complicating matters further, rural communities like 12,500-person Pulaski County struggle to obtain the equipment and hire the people necessary to run ambulances that they’ve already bought.
That can have consequences. Greater shares of Hoosiers are dying because of injuries compared to the U.S. average, according to Centers for Disease Control age-adjusted data from 2016-2020. That signals a trauma care problem in a state that already struggles with low life expectancy. The leading causes of death for Hoosiers aged 1 year to 44 are preventable injuries.
Anyone can experience a traumatic injury, but the problem can be exacerbated in Indiana’s less-populated areas, where a higher percentage of crashes are fatal. Pulaski County, for example, had the highest rate of fatal automobile collisions per person in 2020, and similarly high injury fatality rates over the past five years.
“We just need to fill in the gaps, so that it doesn’t matter whether you live in Indianapolis or Bath, Indiana,” said Dr. David Welsh, a general surgeon in rural southeast Indiana who is on the Indiana State Trauma Care Committee. “You deserve to get good treatment, and good treatment in trauma care makes a difference.”
Unlike other states, Indiana does not possess a statewide trauma plan to coordinate trauma centers, community hospitals and EMS providers. Nor does the state consistently fund trauma care. In a recently released report, the American College of Surgeons (ACS) criticized the system as “generally fragmented and not well coordinated.”
The problems have grown so urgent that they’ve drawn the attention of Gov. Eric Holcomb and leading lawmakers. His administration is attempting to revamp the system and is seeking more money for the state’s trauma system, but it’s not yet clear if it amounts to a Band-Aid when the system needs open heart surgery.
The disparity is evident
One thing Holcomb’s administration wants to do is reduce the number of Hoosiers who live more than 45 minutes away from a trauma center.
That’s because receiving care at a trauma center lowers an injured patient’s risk of death by 25%, according to a 2006 study.
“If you get to a trauma center within the first hour after your injury, then your risk of death or significant comorbidity is significantly reduced,” said Dr. Lindsay Weaver, an emergency medicine physician who serves as Indiana’s chief medical officer.
In Indiana, the age-adjusted injury mortality rate is significantly higher in those regions of the state with no trauma centers, according to the ACS report.
That disparity is evident in the state’s motor vehicle fatality statistics.
Marion County, home to the most trauma centers, had by far the highest total number of collisions in 2020, but it ranked in the bottom half of counties in terms of the percent of crashes that were fatal.
Switzerland County, which is more than 45 minutes away from a trauma center and has no hospital, consistently has a higher percentage of collisions that are fatal than other counties.
“An effective trauma system saves lives, reduces irreversible disabilities and increases quality of life,” said Dr. Paul Halverson, dean of the Indiana University Richard M. Fairbanks School of Public Health. “If you can help save the lives of a young person or reduce their disability but keep them working and productive, it’s not only a good thing for the individual, but it’s a wise investment because they go on to be a productive part of society.”
Helicopters are able to dramatically cut transport times, but they’re usually reserved for the most extreme injuries and can’t fly when the weather is bad.
The number of trauma centers in Indiana has increased substantially since 2008 when there were only seven, Weaver points out. But even today, only Marion County is home to the highest-level trauma center. It’s also the only county with a pediatric trauma center.
Meanwhile, all of Indiana’s neighbors have the highest level of trauma centers scattered in multiple counties across the state.
To start, the Indiana Department of Health is examining hospitals located in Indiana’s dead zones and hoping to transition three into trauma centers.
Closing the gap
Becoming a trauma center, though, would be a tall order for many rural hospitals.
For one, hospitals would have to increase staffing. Even at a Level III trauma center, such as the ones in Elkhart or Bloomington, an orthopedic surgeon must be on site 24 hours a day, and patients must have access to anesthesia and radiology services within 30 minutes. Trauma centers also are required to have a designated injury prevention professional.
Rural hospitals can struggle to keep their doors open and recruit physicians. A report from the Center for Healthcare Quality and Payment Reform found that six unnamed rural hospitals in Indiana are at immediate risk of closing. Further complicating the matter, Indiana lawmakers are pursuing multiple bills intended to lower the cost of health care. Hospitals warn that could have unintended consequences: the closure of hospitals.
Already, more than a dozen rural counties don’t have a single hospital.
Other states provide grants to encourage hospitals to transition to trauma centers, but not Indiana. Arkansas, for example, even provided incentives to hospitals in neighboring states that were closer to many Arkansas residents, said Halverson, the IU dean.
He previously worked as director of the Arkansas Department of Health, where he helped establish the state’s trauma and centralized dispatch systems.
But even if the state provided more funding, multiple rural emergency room leaders told State Affairs it doesn’t make sense for them to transition to a trauma center.
They don’t see the volume of patients necessary to justify buying new equipment or hiring specialized doctors, such as trauma surgeons or neurologists. On top of that, doctors need patients to remain updated on their skills and training.
“To be an expert, you’ve got to do something at least 10,000 times,” said Dr. Ted Seall, Pulaski Memorial Hospital’s emergency department medical director. “For us to get 10,000 gunshot wounds here in Winamac, that would take forever.”
Right now, his emergency room sees about 15 patients a day.
In addition, smaller hospitals typically do not stock the large volumes of blood needed for some trauma patients.
Some states, such as Arkansas, have created a fourth trauma center tier in an effort to bring more hospitals into the system without expecting them to have the same resources as big-city hospitals. But Indiana doesn’t have that option for hospitals.
It’s not that Indiana needs a bunch of Level I hospitals; Indiana needs a functioning and coordinated system, Halverson said.
Lack of EMS providers
If Indiana state government wants to help by creating new trauma centers, rural communities have another idea: Help the EMS.
Hospital administrators say they regularly struggle to transport someone, whether it’s because they can’t find a hospital to admit the patient or there simply isn’t an ambulance available. Hospitals are required to admit patients that arrive directly from a scene. That’s not the case for those coming from another hospital. The delays can last 12 hours or more.
It’s a problem across the state. From 2019 until the third quarter of 2022, at least 29% of trauma patient transfers were delayed, with the most common known reason for delay being an EMS issue.
In Madison, driving to Louisville takes about an hour each way. Occasionally the local hospital’s EMS needs to drive further for certain specialized care, such as behavioral health. When the ambulances are on the road and unavailable, it creates a backup in the Norton King’s Daughters’ Health emergency room while patients wait for their turns to be transferred.
“Transfers are a big part of what we do because we’re all rural,” said Carol Dozier, the CEO of the hospital. “Sometimes we have to go a pretty long distance to get someone to the right facilities.”
Roughly half of Indiana counties have only one ambulance provider, according to Indiana Department of Homeland Security data, and 16 counties reported having as few as four ambulances or less. A handful of counties rely entirely on EMS providers in neighboring counties.
And those numbers appear rosier than reality. Not all of the ambulances are in use due to a lack of staffing. Similarly, some ambulance crews are able to treat only basic injuries.
A staffing shortage, caused in part by low wages, is driving the disparities in care. Rural EMS providers are competing with other health care industries that simply pay better, as well as providers in larger cities, to attract talent.
EMS providers say they struggle to afford the costs associated with training paramedics, let alone attracting enough people into the field in the first place.
The Medicare reimbursement rate isn’t enough to cover the cost to transport patients, and there is no separate funding from the state to run these programs. That means it often falls to local governments or hospitals to eat the costs associated with running EMS.
And the cost of new ambulances is skyrocketing. In a typical year, the cost of a new truck grows about 5% every year; last year, though, it jumped by 35%, said Dr. Scott Smith, a longtime emergency room doctor who runs Adams Memorial Hospital in Decatur.
“Our EMS operates at a loss,” Smith told State Affairs, “and has for as long as I can remember.”
That leaves little left over for salaries and training in some communities with small populations and budgets.
In Harrison County, a 40,000-person county near Louisville, the hospital EMS was so understaffed until recently that it operated with three trucks, instead of the usual five, said Jeremy McKim, the EMS manager.
But the situation is worse in neighboring Crawford County, which does not have a hospital and at times runs only one ambulance. Sometimes Harrison County EMS has to chip in, McKim said.
“We’ve got to figure something out to get people into our industry,” McKim said. “The staff is aging and they’re not going to continue to do this. The rate of people coming into this industry is not meeting the numbers of people leaving.”
Indiana lost 233 ambulances and 1,075 EMS clinicians between 2018 and 2021, according to the ACS. The staffing problems have been exacerbated by a 66% increase in ambulance runs from 2018-2021, said Kraig Kinney, Indiana EMS state director, during a State Trauma Care Committee meeting last year.
“It’s a nationwide trend,” Kinney told State Affairs. “That’s part of the reason the workforce shortage is showing up right now, because not only are we tighter on number of people available, but we have more needs, so everyone is busy.”
How Indiana hopes to fix the problem
State health leaders realize the trauma system has gaps. In fact, it was the state that invited the ACS to evaluate Indiana’s system in November.
But the list of recommendations from the ACS is lengthy, and ranges from creating a trauma system performance improvement plan, to completing an EMS workforce assessment, to securing ongoing funding. The ACS, though, did not recommend a specific dollar amount needed to rightsize the system.
The two-year proposed budget contains $9 million over two years for “trauma system quality improvement,” which Weaver said can be used to better coordinate trauma care across the system, identify current problems using data analysis and focus on prevention. Ultimately, the Trauma Care Commission — which would be codified under the public health bill, Senate Bill 4 — would provide oversight on how to best use that money, she said.
Is the money enough? “I think you have to start somewhere,” Weaver told State Affairs.
There’s no guarantee that funding will go toward encouraging more hospitals to become trauma centers or current trauma centers, despite the recent recommendation from the ACS to provide financial incentives encouraging participation in the state trauma system in both its 2008 and recent report.
An additional $14.6 million would be set aside for EMS under the budget that can be used for recruitment, training and new ambulances. It also can be used to ensure the closest emergency departments are responding when dispatched.
The state is also already undergoing the recommended EMS workforce assessment. Plus, if SB 4 passes as is, the Trauma Care Commission would be tasked with developing a statewide trauma plan. Some changes might also have to come in future years.
The House passed the budget Thursday and the bill now moves to the Senate, where Senate President Pro Tempore Rodric Bray, R-Martinsville, and other senators have signaled a willingness to fund the trauma care proposal.
"We live in a state where a significant impact on how long you live, is where you live,” Sen. Ed Charbonneau, R-Valparaiso, said when discussing SB 4 on Thursday.
But perhaps nothing shows the need for trauma care system changes more than an anecdote DeLorenzo shared of a patient who fell off the roof of his home. Because of the winter weather, no emergency helicopter could fly, which meant the man had to be transported to the local, non-trauma center hospital to be stabilized.
After he arrived at the local hospital, though, staff struggled to find a trauma center that could accept the patient, he said. The only option: a Level III center, when in reality, DeLorenzo said the man’s injury would usually need a higher caliber trauma center.
On top of that, icy roads slowed the drive to two hours.
“That was not good for that patient,” DeLorenzo said. “We’re in the middle of nowhere, so when you’re max speed of 30 miles per hour, trying to stay on the road and go 20 miles to a call, it takes a long time.”
While DeLorenzo is not certain whether the patient survived his injuries, he still wonders if he had been transported more quickly, or had been moved to a higher level trauma center, whether the man’s chances of survival would be greater.
Contact Kaitlin Lange on Twitter @kaitlin_lange or email her at [email protected].
Contact Ryan Martin on Twitter, Facebook, Instagram, LinkedIn, or at [email protected].
Header image: Pulaski County EMS, which typically runs two ambulances across the county's 435 square miles of mostly farmland, is headquartered in Winamac, Indiana, Feb. 7, 2023. (Credit: Ryan Martin)
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