By Julie Washington
cleveland.com
CLEVELAND — Would another trauma center in Cleveland be a boon or a boondoggle?
The Cleveland Clinic’s plan to create a new adult Level 1 trauma center, staffed by surgeons around the clock to treat the most severe injuries, is raising concerns about whether Cleveland needs a third facility.
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Critics question whether another center — on top of those already operating at University Hospitals and MetroHealth — would save more lives or simply duplicate services in an already saturated market.
Some common metrics typically used to assess trauma care capacity suggest Cleveland may already be well served with two. Experts say a third would not significantly improve EMS transport times or regional readiness for large-scale emergencies. And they say it could dilute patient volumes at existing centers, creating problematic ripple effects that deprive them of the constant practice that keeps trauma teams sharp.
“It’s hard for me to really understand, from a supply and demand perspective, what the justification is for a third trauma center, especially when the [ UH and Clinic centers] are so close together,” said Ray Herschman, adjunct professor of health care finance at Case Western Reserve University’s Weatherhead School of Management.
One thing is certain: Adding a Level 1 center would be a final jewel in the Clinic’s crown.
Despite being the largest healthcare provider in Ohio and one of the top in the country, it is the only large U.S. healthcare system that doesn’t have a Level 1 trauma center, Clinic CEO Dr. Tom Mihaljevic said recently.
Adding one could put the Clinic on the same level as the country’s premier hospital systems in national rankings.
The Clinic says its decision isn’t based on a desire for prestige, but a desire to better serve its patients and region. A Clinic trauma center would reduce patient transfers between health systems, cutting associated risks and costs, the health system said.
MetroHealth — which pioneered trauma care in Cleveland with the city’s first Level 1 adult trauma center — calls the plan “reckless.” MetroHealth also raised concerns in 2015, when University Hospitals opened Cleveland’s second Level 1 trauma center, citing the East Side’s lack of one.
“It is deeply concerning that this announcement appears to have been made without regional planning, stakeholder consultation or a demonstrated community need,” MetroHealth CEO Dr. Christine Alexander-Rager said in a Feb. 2 letter to the Clinic. “Your plans to open Cleveland’s third Level 1 trauma center will not benefit the community.
Instead, these plans carry a meaningful risk of harm to patients, our regional trauma system and affordability.”
Hospitals with Level I trauma centers are able to treat life- or limb-threatening injuries, including gunshot or stab wounds, serious falls, traumatic brain injuries, car crash injuries, industrial accidents and blunt force trauma. The Ohio Division of EMS and the American College of Surgeons oversee verification of new trauma centers, with the ACS issuing national guidance. The verification process usually takes about 18 months.
Here’s a look at the questions surrounding the Clinic’s proposed trauma center:
Would an additional Level 1 center lower EMS response times?
The city of Cleveland’s EMS ambulances transport trauma victims with life-threatening injuries to the closest Level 1 center.
If the Clinic’s main campus added one, Cleveland EMS commissioner Orlando Wheeler said transport times would only be trimmed by one or two minutes, because the UH center is only about one mile away.
A third trauma center also isn’t needed in the event of a regional mass casualty event, Wheeler said. UH and MetroHealth are able to rapidly treat multiple trauma cases at once, and less severely injured patients would be sent to Level 2 and Level 3 trauma centers throughout the region, Wheeler said.
Is it needed based on Cleveland’s population?
Guidance from the American College of Surgeons, which sets some criteria for the nation’s trauma centers, suggests that only 1 to 2 Level I or II trauma centers are needed per million population, according to a 2003 JAMA article.
Cleveland.com compared Cleveland with several metropolitan areas of similar size, using the number of Level 1 adult trauma centers relative to population.
As it stands today, Cleveland, with a Metropolitan Statistical Area population of about 2.1 million residents, has a ratio of one Level 1 center per 1.05 million residents.
Adding a third center would move Cleveland’s ratio to 700,000 residents per center.
In Indianapolis and Pittsburgh, which each have three centers, there are 700,000 to 800,000 residents per center.
Nashville and Columbus each operate two, with roughly 1.05 million to 1.1 million residents per center.
San Jose operates a single Level 1 center, serving about 1.9 million residents.
Adding a third trauma center at the Clinic would place Cleveland alongside Indianapolis and Pittsburgh . Remaining at two would put Cleveland closer to the ratio in Nashville and Columbus.
“If our ratio was one trauma center to every 2 million, and you could make the case that we needed more capacity, more supply, then (a third center) would make sense,” CWRU’s Herschman said. “But we already have more than enough capacity.”
A needs-based assessment of trauma center distribution around Ohio — conducted by the Northern Ohio Trauma System in 2019 using ACS guidance — suggested there was no need for additional trauma centers in Northeast Ohio, which was defined as Lorain, Cuyahoga, Lake, Geauga and Ashtabula counties.
Its study found that the number of severely injured patients seen in Level 1 or Level 2 trauma centers in Northeast Ohio was much lower than expected based on the region’s population.
The organization is a collaboration between the Clinic, UH, MetroHealth and Southwest General Health Center.
What are the Clinic’s reasons for wanting this?
The Clinic has said it wants to add a trauma center to better serve its patients and the region.
“We want to address what’s been a gap in our continuum of care,“ Dr. Scott Steele, president of Cleveland Clinic main campus, said during a recent Ward 6 community meeting. Ward 6 includes the Clinic’s main campus.
“We want to be able to treat all of our patients, and be able to do that from the moment of impact within our system,“ Steele said. ”Obviously, we feel that we have the expertise and the experience to take care of the most complex medical and surgical patients, and we also want to be able to do that for our trauma patients.”
It also wants to keep more patients within the Clinic system, instead of transferring them to trauma centers at UH or MetroHealth. Keeping patients at the Clinic will lead to improved outcomes and continuity of care, the health system said.
For example, future trauma patients who suffer brain injuries would benefit from subsequent care at the Clinic’s under-construction $1.1 billion Neurological Institute, Mihaljevic said.
The Clinic currently transfers several hundred trauma patients out of its care annually. Transferring patients between hospital systems introduces chances for things to go wrong. It incurs expensive ambulance bills and possibly the need for duplicate scans and tests, the Clinic said.
When recently asked if the Clinic could point to a feasibility study showing a need for additional trauma centers in Cleveland, Mihaljevic did not answer directly. He instead said there was “a great need” for the Clinic, in particular, to offer trauma care.
Having a Level 1 center “is about providing those patients with the best care possible,” Mihaljevic said. MetroHealth trauma surgeon Dr. Joseph Golob disagreed.
“I’m not necessarily feeling that the Clinic wanting to transfer a patient from one of their satellites into the main campus is a good enough reason to open a trauma center,” Golob said. “You may be flying that patient over a Level 1 that already exists.”
What is the criteria for deciding whether to add another center?
Trauma care needs should be assessed by looking at criteria that include percentage of population within 60 minutes of a Level I or Level II center, EMS transport times, rates of trauma-related deaths, and the frequency of inter-hospital transfers to access specialized care, according to the ACS.
However, trauma center designations sometimes are “driven by the needs and ambitions of individual health care organizations” rather than patient needs, the American College of Surgeons said in a 2021 statement.
“Recent changes in health care economics have made trauma center designation generally more desirable, and certain areas have developed a perceived oversupply of high-level trauma centers with potentially adverse effects on cost and efficiency of patient care,” the statement said.
Would there be enough cases?
The ACS requires that a Level I adult trauma center care for at least 1,200 trauma patients annually, saying that adequate patient volume is important for clinical proficiency, as well as innovation, research and education.
Mihaljevic said he is confident there’ll be enough trauma cases to meet the quota when the region’s trauma cases are split among MetroHealth , UH and the Clinic.
MetroHealth’s Alexander-Rager disagreed in her letter to the Clinic.
Trauma surgeons, neurosurgeons, nurses and other trauma team members are like members of a racing pit crew, she explained.
“Skills stay sharp and synchronize only when they are performed at high volumes, over and over,” Alexander-Rager said. “Higher-volume trauma centers achieve better survival rates.”
Having a third trauma center in Cleveland also could dilute the region’s talent pool of trauma specialists, she said.
CWRU’s Herschman agreed with MetroHealth.
“Where’s the trained, experienced staffing going to come from?” he said. “It takes a very highly specialized skill set to run a trauma center.”
Losing patient volume also could cause operating costs to be spread out among fewer patients, Herschman said.
“The overall cost to run three adult trauma centers is going to go up, because you’re spreading that fixed cost over fewer patients at each of the three places,” Herschman said.
In other words, demand for trauma care isn’t going to skyrocket, meaning the Clinic will be pulling patients from MetroHealth and UH, and all three would face higher per-patient costs.
Currently MetroHealth treats more than 7,000 trauma patients every year.
UH declined to give the number of trauma patients it treats annually, or weigh in on the potential need for a third one.
“We hope to be able to work together across the Level I trauma providers to ensure that our community always has access to the best trauma care,” UH said in a statement.
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