The San Diego County Trauma System

San Diego’s trauma system is considered to be one of the finest in the United States, and the Mercy Hospital Trauma Service has played an important part in it since its inception.

Current features include:

• Trauma center-specific catchment areas with shared jurisdiction over international border regions
• Monthly medical audit committee meetings between representatives from all centers
• Optimal allocation of pre-hospital emergency medical services (EMS) throughout county
• Robust trauma triage criteria

The system began in 1982 when the local Hospital Council commissioned an assessment of the need for a trauma system in San Diego. The resulting report, known as the Amherst Study, revealed that 46.9 percent of trauma patients studied received sub-optimal care and that 21.2 percent of the deaths were either frankly or potentially preventable.

In 1984, the trauma system was approved by the San Diego County Board of Supervisors. A subsequent more stringent study examined the outcome changes before and after institution of the trauma system, and revealed that before implementation, the care of major trauma victims was sub-optimal in 32 percent of cases with preventable deaths at 13.6 percent. After the system was in place, the number of patients who received sub-optimal care dropped to 4.2 percent, and preventable deaths dropped to 2.7 percent.

Trauma centers and Catchment Areas

The San Diego County trauma system includes six trauma centers. These are definitive care facilities that together provide a spectrum of care for all injured patients. They are regulated under California Code of Regulations, Title 22, Division 9, Chapter 7. They also undergo a verification process every three years whereby the American College of Surgeons Committee on Trauma (ACS-COT) evaluates each center for the resources needed at various levels of facilities to provide optimal care. Level I trauma centers, besides having acute care responsibilities, are teaching hospitals which have the responsibility for conducting research and providing injury prevention programs and system leadership. Level II trauma centers are often the most prevalent facilities in a community and together manage a majority of the patients. Level III and IV centers serve communities that do not have immediate access to a Level I or a Level II institution. San Diego’s trauma system is comprised of two adult Level I centers (Scripps Mercy Hospital, UCSD Medical Center), three adult Level II trauma centers (Scripps Memorial Hospital, Palomar Medical Center, Sharp Memorial Hospital), and one pediatric Level I trauma center (Rady Children's Hospital).

Each trauma center receives trauma patients injured in a defined area in the County known as its “catchment area.” Scripps Mercy’s catchment area encompasses the southeast section of San Diego County bordered on the west by highway 805, on the east by highway 94, and on the south by the Mexican border. Trauma center admissions have risen steadily since the system’s inception. Scripps Mercy Hospital Trauma Center today sees over 2600 patients per year. 

San Diego Medical Audit Committee

The San Diego EMS Medical Audit Committee (MAC) acts as the quality assurance entity for the county.  Composed of EMS staff, the county medical examiner, each hospital's trauma medical director, and nurse managers, this committee meets monthly to evaluate unique trauma cases in order to improve the quality of care delivered by all trauma centers. Under this peer-review process, each trauma-related death is classified as preventable, potentially preventable, or non-preventable, and used to identify effective (or ineffective) methods of treatment.  Morbidity occurring iatrogenically or due to a flaw in the delivery of care is evaluated and procedures are revised to improve both the quality and efficiency of care for each patient.

This process allows for the minimization of personal or center-specific biases related to physician decisions, the classification of mortality, and the causal classification of morbidity. The San Diego MAC has been considered a model quality improvement program for the nation’s trauma systems.

Pre-hospital Services

San Diego pre-hospital services are responsible for delivering basic (BLS) or advanced life support (ALS) care on site of incident trauma events. Conditional on the consciousness status of the patient, pre-hospital services are also responsible for transporting patients to the proper hospital for the delivery of specialized. Additional information, including annual reports, procedures, and participating agencies can be viewed at the San Diego County EMS website.

Trauma Triage Criteria

The trauma triage criteria of San Diego County was originally based on a decision tree algorithm developed in 1984. Eventual updating occurred in 2000 based on recommendations made by the American College of Surgeons. Triage of patients to a trauma service (versus an emergency department) requires coordination between pre-hospital emergency medical services and each base hospital within a specific catchment area.

The triage process begins with an evaluation of basic vital signs and age, with subsequent evaluation of injury features. If characteristics of the injury are indeterminate, aspects of the mechanism of injury are evaluated to identify probable cause for evaluation by a trauma service. Pre-existing conditions (a.k.a "comorbidities" or "chronic diseases") and aging-related patient characteristics are evaluated towards the end of the triage protocol. This also includes medication use patients of advanced age that is concurrent with head injury or loss of consciousness.

Finally, a catch-all is used where if a patient is truly not looking well, they are transported and evaluated by a trauma service. Eventual downgrading of a patient to the emergency department may occur after successful stabilization and if trauma is not the primary ailment.