Paoli Hospital to Become Designated Level II Trauma Center for Chester County

Today it was announced that the Pennsylvania Trauma Systems Foundation has accredited Main Line Health member Paoli Hospital as a Level II Trauma Center. For a hospital to operate as a Level II Trauma Center requires a volume of 350 major trauma patients per year. Chester County is the only county in southeastern Pennsylvania that does not have a trauma center.  Since Brandywine Hospital closed in 2002, there has not been a designated trauma center in Chester County but that will change come October 1. 

After Paoli Hospital’s $145 million patient care pavilion project opened in 2009, the hospital volunteered to serve as Chester County’s trauma center.  With the four-story pavilion project nearly doubling the hospital’s size and the expansion of the emergency department, the administration suggested that the hospital had room for a trauma center and applied for that designation.  Today it was announced that Paoli Hospital received the accreditation. 

I am not clear how Paoli Hospital is going to fund this new trauma center.  After major fund-raising for the pavilion project, it is estimated that the trauma center will cost approximately $7 million for the first year and continuing to rise each year.

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  1. With as many Level 1 Trauma centers within a 30 minute ambulance ride or 10 minute helicopter flight as we have already, I cannot imagine why our northeastern region of chesco needed a level 2 trauma center in Paoli.

    If i were to be injured so seriously that I needed trauma center care, PLEASE send me to one of the level 1’s in the city that are experienced in dealing with and saving seriously injured patients every day.

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  2. Cannot sit quiety for this one. I know we are all proud of the quality of the doctors who serve out of Paoli hospital, and the emergency room has some great docs — but Paoli is NOT a trauma center, whatever designation they get. After 6:00 at night, Paoli Hospital has ZERO doctors in the building except those in the emergency room. (Oh – -and the ones that are staying late). They are not a teaching hospital and do not have residents or interns — just Physician’s assistants…(which are billable as opposed to the others). Should we get tattoos that say DO NOT TRANSPORT TO PAOLI in case of an emergency? If you can get yourself there, and you are sick, it’s all good. But for a true trauma, Paoli better have a helipad — as they don’t have the 24/7 care that a trauma center requires. I don’t know what they plan to add for $7M, but any building without a teaching function is not likely to be well staffed after hours with a medically savvy staff., or a hierarchy of medically trained professionals. It’s a great place to get treated, but not saved. Right now they are a cardiac center — yet have ZERO cardiologists on the premises unless they are in their office or visiting a patient.

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  3. Style Observer makes excellent points. It should also be noted that many of these issues with a Paoli Trauma Center are the same challenges that Brandywine Hospital would have had when it’s trauma center was active – and we can all see how that ended. What is it that PMH will do differently (better) than Brandywine when it had a trauma center?

    It is also worrisome that their trauma accreditation depends upon their treatment of such a large number of trauma cases annually – clearly this requirement is a disincentive to PMH ever sending a trauma case to a better equipped facility.

    The contrasting depths of experience, staff, facilities, and resources between PMH Trauma, and that of the Level 1 facilities in the city is enormous. It makes no sense for a trauma patient from this locale to ever go to Paoli for trauma care – especially with the availability of medical helicopters to bring a higher level of care to the field and to shorten the transport time to Philadelphia to 10-15 minutes.

    We are very lucky to have the Level 1’s in the city so accessible, having a lesser center closer doesn’t fill any gap in service.

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  4. I find it interesting that both Style Observer and Golden Hour question the location of a Level II Trauma center at PMH.

    I hope those in the position to defend this decision weigh in on Community Matters.

    As a long-time area resident, I find this very positive news. Though not centrally located in the county , it will no doubt provide life-saving benefits to many in the years to come.

    Because of its location near many major roadways, PMH’s trauma center will be handling traffic accident victims

    Since it is within 15-20 minutes of many surrounding communities, local EMT’s can make assessments in consultation with doctors and potentially get critical patients to life-saving care faster. .

    Re the suggestion that PMH might not send critical patients to a Level I Trauma center when needed ( in order to meet its trauma quota???) seems quite unlikely. PMH has earned its reputation as a top-notch regional hospital for a reason. I trust patients will be properly assessed by medical staff.

    Re PMH’s current lack of emergency doctors of staff, I’m confident that in earning their Level II Trauma certification, PMH has a plan in place to meet every contingency..

    Last. this news reflects well on former State Rep Carole Rubley, who has worked tirelessly to establish a Trauma Center in Chester County.

    We should have one, and now we will.

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    golden hour Reply:

    Kate – Your speculative response is built upon your blind trust in PMH and supported only by the reputation you perceive that PMH has – not exactly the dataset I would bet my life on. My concerns are based upon very real experiences with all of these hospitals.

    To the extent that it is your choice which trauma center you may be transported to, I would suggest you select very carefully, your life may depend on it.

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    golden hour Reply:

    Kate – Regardless of the reputation of Paoli ER and PMH in general, would you disagree that HUP and Hahnemann have far superior reputations to PMH with respect to emergency medicine and treatment of trauma?

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  5. I would need to see what plans will come with this new designation. Obviously having a trauma center has benefits, but not without major changes to the PMH approach to medical care for patients coming in for non-scheduled service. I have to echo the two detractors above — there are no doctors to take care of patients during the night. My mother was given great care in the ER, but once she was transferred to the floor, she got no medical attention. The nurses were great, but the “doctor” on the case sent his PA who was seeing his pateints in 3 locations and didnt’ get to PMH until mid-morning ( she was admitted at dinnertime the night before). . We ultimately transferred her by ambulance (which Paoli would not accomodate nor secure — their own ambulance is owned by the a pc of PMH doctors and sat unused at the ER entrance) into the cardiac ward at Penn…where she subsequently had surgery.
    Coincidentally, I had an emergency several weeks later and went to Bryn Mawr ER– where the resident agreed to transfer me to Penn after consultation with my doctor. Ironically, the ambulance driver that took me (along with my records which Bryn Mawr sent with me on disc) in the middle of the night (arranged for by Bryn Mawr) was the same independent service we had to call for my mother’s transfer. SO — two hospitals, same “owner” but the teaching hospital had medical decisions made by medical doctors. PMH had a social worker trying to advise us not to move my mother, and that they would have a cardiologist there within 6 hours….they removed her IV and discharged her “AMA”….though no “M” ever saw her once she entered the hospital as a patient.
    PMH is a wonderful place for scheduled medical treatment, where you are admitted by your doctor and managed by his/her practice. But absent any major changes to their approach to medicine (no teaching and therefore no “on call” room for doctors)…you could definitely fall through cracks.

    The suggestion the PMH might not send critical patients to a Level 1 trauma center may sound unlikely, but the fact is that a trauma might be sent to PMH that doesn’t belong there, losing precious time better spent getting to a Level 1 center with 24/7 medical staffing.

    All this is somewhat moot given the time frame….but an interesting take/debate.

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  6. To those that think the staffing issues will be rectified by October 1… They won’t. Their current staffing level is the same exact as what will be in place on October 1. That won’t change.

    This is not needed in the county. Would you rather be treated by physicians/surgeons in a “trauma center” that will struggle to make the 350 patient requirement. Or would you rather be treated by an EXPERIENCED medical staff that easily triples/quadruples that number.

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  7. From PA Standards

    “A trauma center is much more than a hospital emergency department. A team of specially trained physicians, nurses and other health care professionals is available 24 hours a day, seven days a week to care for traumatic injuries. The team includes board-certified general surgeons with additional training or interest in trauma surgery and critical care, and nurses certified in trauma nursing. Both nurses and physicians are required to maintain annual continuing education related to trauma to ensure the provision of state-of-the-art trauma care. A trauma surgeon is always available in the hospital, ready to care for trauma patients.

    Anesthesiologists are available around the clock to assist in providing diagnostic and interventional radiologic services and operative services. Additionally, neurosurgeons and orthopedic surgeons are immediately available to the Trauma Center, if needed. ”

    Bill L — does this infer that PMH will have a 24/7 surgeon, or simply one “on call?”

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  8. Some clarification on some of the statements above.

    1) Bryn Mawr is NOT a teaching hospital.
    2) Both Bryn Mawr and Paoli DO NOT have their own ambulances. They typically utilize contract services of Transcare Ambulance. Also, Main Line Health is associated with Jefferson Health System who has JeffStat Medical Helicopter as well as transport ambulances. There are typically only 4-6 transport ambulances for those services on status over night for the whole region.
    3) Paoli Hospital already has HMS doctors in the Hospital 24/7 (minimum 2). This is not new and has nothing to do with Trauma.
    4) Since the trauma initiative, there is Trauma Doctor and associated staff (respiratory, anesthesia, OR staff) in the hospital 24/7. A large majority (if not all) of the ER nurses were sent to class to be certified as Trauma nurses and are a part of that team.
    5) 90% of Hospital treatment is performed directly by Nurses. The fact is that Doctors give orders for nurses to follow. If something should change the would deem a medical concern, the nurse has direct opportunity receive updated orders or follow protocols to work on a solution.
    6) Believe it or not, Physician Assistants provide a massive amount of medical care in hospital settings. This is nothing out of the ordinary.
    7) Level 2 Trauma Centers have their place in the world of Trauma. Not every Trauma patient will be taken there. EMS providers will have protocols to follow that will dictate what type of facility their patient requires. If anything, this will enhance the level of service to non-extreme levels of trauma (simple non-compound broken leg = not trauma) that would now see a trauma MD, rather then a genera ED MD. There will still be plenty of trauma patients that will go to level 1 trauma centers. It is NOT UNCOMMON for Level 2 centers to send Patients out to Level 1. Paoli will not be unique to this. The primary advantage will be the border line or low level trauma patients that were being sent to the city that will be adequately handled by a Level 2. At a minimum, this will reduce extended transport times of patients that do not need level 1 facilities.
    8) Do not forget that many patients who are trauma candidates walk in the door themselves. Things like falls with sub-cranial bleeds may often come in the door because they get someone to drive them in after they don’t feel well after a fall. Many accident victims walk in after refusing EMS transport. There is no way to control those factors because unlike EMS units, individuals have no protocols to follow.

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    Bill L. Reply:

    “7) Level 2 Trauma Centers have their place in the world of Trauma. Not every Trauma patient will be taken there. EMS providers will have protocols to follow that will dictate what type of facility their patient requires. If anything, this will enhance the level of service to non-extreme levels of trauma (simple non-compound broken leg = not trauma) that would now see a trauma MD, rather then a genera ED MD. There will still be plenty of trauma patients that will go to level 1 trauma centers. It is NOT UNCOMMON for Level 2 centers to send Patients out to Level 1. Paoli will not be unique to this. The primary advantage will be the border line or low level trauma patients that were being sent to the city that will be adequately handled by a Level 2. At a minimum, this will reduce extended transport times of patients that do not need level 1 facilities.”

    _________________________________

    Level 2’s do have a place, but not this close in proximity to the Level 1’s. Because what happens, contrary to your posted examples/beliefs, the patients that should be at Level 1’s now get diverted there as well.

    These protocols that you state that the EMT’s have, DO NOT differentiate between a Level 1 or Level 2 trauma center. So guess what, that trauma patient that suffers the catastrophic fall and has a head injury, multiple long-bone fractures, and internal chest injuries will be going there as well. When in reality they desrve the tertiary care facilities downtown. So check your facts before trying to come on here and say that the acute patients will still be going to the appropriate facility. Because they won’t. And I work for PMH, but this is the last thing that was appropriate for the residents…

    Oh, and that fall victim, they’ll probably still get downtown, but not until we hold onto them so long that it will be too late for the hospitals downtown to do anything about them. As is the case with the majority of Level 2’s. We think we’re one of the big boys, when in reality, we’re just going to be elementary.

    What is wrong with over-triaging patients” By that I mean, thinking their injury is more serious then it ends up being and sending them downtown when they end up not needing it? It is better than the alternative, is it not? The entire realm of emergency healthcare is built around a certain level of anticipated over-triage. Unfortunately, that has the effect of raising the costs to a certain degree. But it helps to catch the patients that would otherwise slip through the cracks and be undertreated. Better to over-treat and live, than under-treat and die….

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    golden hour Reply:

    Trauma2 says: “The primary advantage will be the border line or low level trauma patients that were being sent to the city that will be adequately handled by a Level 2. At a minimum, this will reduce extended transport times of patients that do not need level 1 facilities.”

    Who will diagnose a patient as borderline or low level trauma in the field? Which field triage system defines the level of trauma center that a trauma patient should be transported based upon their injuries, actual or suspected? This is not typically how it works – the severity of traumatic injury is often largely unknown and is diagnosed IN the trauma center – hopefully the same facility is capable of treating the injury. This is where Paoli Level 2 will potentially waste precious time at best, at worst they will provide a lessor level of care.

    The time to find out that HUP, HUH, TJUH, TUH, AEMC, etc. would have been more appropriate facilities to treat an injury(s) is not when you are in, and committed to, the PMH system.

    Extended transport times? Most often these trauma patients are transported via medical helicopter:
    – their transport times are not significantly longer then an ambulance ride to PMH,
    – the flight crew is bringing more advanced tools and skills to the scene,
    – ultimately local EMS providers are available sooner than if they had to transport to a local hospital.

    —-

    Trauma2 says: “It is NOT UNCOMMON for Level 2 centers to send Patients out to Level 1”

    Where does this happen? and what are the circumstances? Currently it is not uncommon for local ER’s to accept patients into their ER that should’ve been directed to a local trauma center. Then after realizing they lack the capabilities/facilities to treat they transport or fly them out. This process wastes time and adds significant risk. But this is still the best scenario compared to a patient staying within PMH who would be better off at a more advanced facility.

    In the end you cannot argue that the depth of resources and experience are now, and will always be, profoundly in favor of the Level 1 trauma centers in the city over PMH – for that reason alone that is where I would prefer to be treated if I am ever critically injured.

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    ANON Reply:

    My experience with the ambulance and the PA system is what it is — whatever the protocol should be. An 84 year old was denied access to medical treatment pending the arrival (within 6 hours) of a cardiologist…PMH would not transfer her. She was taken by private ambulance (while an ambulance sat in the ER bay unused — and those drivers were annoyed when another service arrived). It was a saturday. She arrived at Penn, was transfused for massive losses of blood, and had surgery the next day. Because we did not sue PMH does not mean there was adequate care offered. A month later, I had a completely different experience at Bryn Mawr — with cooperation and the patient well being at the center of the experience. I ended up avoiding surgery at Penn…but Bryn Mawr did not try to claim me.
    Bottom line — I don’t want an ambulance to take me to Paoli….not because the people at paoli are not wonderful — but because they are all associated with PMH, they don’t work there.

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  9. It is my understanding that most of the Surgeon staffing requirements are the same with Level 1 and Level 2 trauma centers. They are either required to be in-house or “promptly available”. Now, I guess “promptly available” (actual wording from the Standards) can be interpreted many different ways.

    With the Level 1 and all of the educational facilities that come along with it, your chances of them being in-house are obviously significantly greater.

    Paoli has just completed their evaluation process that started at the beginning of the year. Starting January 1, they were required to begin staffing the hospital at the level they would for the trauma center accreditation. They would then be evaluated on how they handled any walk-in trauma’s and trauma’s under-triaged by field providers. They were supposed to be evaluated on their handling of those patients and the administration of those patients. I know for a fact that some of the county’s EMT’s brought patients to them that were intentionally under-triaged, in order to help bost Paoli’s numbers. Even with this non-compliance with protocols, Paoli had to petition the state to allow them to be evaluated early, citing they weren’t getting the numbers they would need.

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  10. Thank you all for your input and obvious expertise. My clear concerns are borne out — that a mis-diagnosed” level 1 will be transported to PMH and lose precious time getting to a hospital that is prepared to deal with the injury/accident appropriately. The “promptly available” standard means within 15 minutes of the ambulance arrival at the facility….which could obviously be considerable time from the 911 call to the actual surgery consultation.

    BM may not be a teaching hospital, but I have also experienced late night medical response there from residents….so I cannot account for the process. I do know from my experience with medical billing that PA’s are billable and residents are not….so there is a profit motive for using PAs. The trauma designation requirements might limit this use because it doesn’t allow an emergency responder to be “on call” for more than one location — but I am all too closely familiar with people dying at PMH because of an “off hours” emergency post-surgery or post-trauma.

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  11. The protocol does not prohibit transporting patients to a level 1 trauma center. Experienced field providers will know when the patient belongs there.

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    Bill L. Reply:

    Actually, Trauma 2, you either need to read their protocols a little better, or you need to refrain from your misleading statements. 

    There are no protocols prohibiting providers from going to a Level 1, per se. However, the State Protocols do not recognize the differences between the different levels of trauma centers and DO prohibit them from bypassing one trauma center for another unless based on certain distances. Otherwise I can guarantee that the majority of your “experienced” providers in the region would be bypassing Paoli were that option available. 

    Coincidentally, there is a growing trend at the state level include that recognition of the trauma center capabilities. Oddly enough, this has been a recommendation of the American College of Surgeons and other medical advisory groups for years. Yet, Pennsylvania still hasn’t adopted these policies. Can anyone say “Standard of Care”?  Yet this is the same state that has granted Paoli “Trauma Center” status…..

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    Township Reader Reply:

    This one I can comment on — I work with an ICU doctor from a Level 1 center who cringes when he has to run a code with a pediatric trauma in our area…and will in any possible case, divert it from Paoli. The folks at Paoli are good people — but they are not prepared for (and I dont’ want them in the way of) level 1 traumas. I don’t know “protocols” but I have lots of friends that are EMTs….and I know that they feel pressure to take people to local sites….

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  12. It’s clear that a number of commenters have an inside perspective on PMH’s ability to handle trauma patients with properly trained personel in a timely manner.

    I’m very troubled by what sound like serious concerns.
    And Golden Hour, you’re right about my “data”.being lacking. This is no time for blind support. If PMH medical personnel and area EMT’s believe accessing a Level 1 Trauma center improves a patient’s chances of survival and that Paoli is not equipped to handle some who arrive needing critical care, then people need to give great weight to that..

    Is there another side to PMH’s new designation? Are there any supporters among CM readers.?

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  13. Good conclusion Kate. As a consumer, how can we protect ourselves from transport to the wrong center? I’ve never needed an ambulance — and presumed that being able to drive or be driven freed me to make my decision based on my own condition. The ER at PMH has always been attentive, but I’ve never been admitted there. I’m assuming trauma care includes ultimately an admit to the hospital — so should we be trying to encourage PMH as a center, or try to shine a light on the fact that in this region, too many Level 1s are far more appealing an outcome….at least for ambulance transport. PMH can always handle the “walk in” traumas…

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