EDINBURG, RGV – The Rio Grande Valley region has secured $6 million from the State of Texas to boost efforts to land a Level 1 Trauma Center. 

The item was one of the top legislative goals of Valley lawmakers, as well as hospitals such as DHR Health.

News that the Valley had succeeded in its goal came in an op-ed from state Sen. Juan Hinojosa of McAllen.

“We were proud to secure $17 million to strengthen trauma system infrastructure. In South Texas, we have many great hospitals but not a Level 1 trauma facility. We are proud that at least $6 million of the trauma funds will go towards ensuring that South Texas has a life-saving Level 1 trauma center in the near future,” Hinojosa wrote, in a guest column about the 86th Legislative Session.

The additional funds came about through a supplemental appropriations bill – SB 500. The funds will be administered through the Department of State Health Services. Here is the relevant section of SB 500:

In addition to amounts previously appropriated for the state fiscal biennium ending August 31, 2019, $17,000,000 is appropriated from the economic stabilization fund to the Department of State Health Services for the two-year period beginning on the effective date of this Act for increasing trauma capacity and improving related trauma response infrastructure under Strategy B.2.1., EMS and Trauma Care Systems, as listed in Chapter 605 (S.B. 1), Acts of the 85th Legislature, Regular Session, 2017 (the General Appropriations Act).

Of the amount appropriated under Subsection (a) of this section, $2,000,000 may be used only to provide funding in accordance with Section 780.004, Health and Safety Code, to trauma service area regional advisory councils for improving emergency management services.

Of the amount appropriated under Subsection (a) of this 20  section, $15,000,000 may be used only to provide funding in accordance with Section 780.004, Health and Safety Code, to hospitals that demonstrate regional need and the ability to efficiently and effectively increase trauma capacity and improve related trauma response infrastructure.

The Department of State Health Services shall allocate: at least 40 percent of that amount to provide funding to hospitals in the Rio Grande Valley, prioritizing, to the extent consistent with general law, primary teaching hospitals in that region with a general surgery residency program pursuing designation as a level I trauma facility; and not more than 40 percent of that amount to provide funding to hospitals located in a region directly affected by Hurricane Harvey.

Any funding provided to an entity under Subsection (b) or (c) of this section that is not spent for the purpose for which the funding was provided must be returned to the state.

The unexpended balance of money allocated as provided by Subsection (b) or (c) of this section as of August 31, 2020, is appropriated to the Department of State Health Services for the state fiscal year ending August 31, 2021, for the purpose for which it was allocated.

Securing funding for a level one trauma center was not just a top agenda item for Valley lawmakers and hospitals. Gov. Greg Abbott said it was important also.

“I strongly support a Level 1 Trauma Center in the Rio Grande Valley. It’s unacceptable that severely injured patients are sent all the way to San Antonio for emergency care,” Abbott tweeted at the start of the legislative session.

Earlier this year, DHR Health asked Hidalgo County Commissioners Court to pass a resolution in support of a Level One Trauma Center. Its physicians pointed out that in an emergency, when a patient has suffered severe trauma, the best care can be found at a level one trauma center. They said a level one center has to meet rigorous standards to receive certification.

Dr. Raúl Barreda, DHR Health’s trauma director pointed out that although there is a Level II trauma facility in Cameron County, the nearest Level 1 Trauma Center is at a hospital over 240 miles away in San Antonio.

“The trauma network recognized a glaring hole when Hurricane Ike hit in Houston,” Barreda told commissioners. “The county has no Level I facility.”

Dr. Carlos Cardenas, chairman of the board of DHR Health, pointed out that the Trauma Network in the State of Texas is comprised of 22 regions and includes 18

Level I Comprehensive Trauma Facilities, 21 Level II Major Trauma Facilities, 56 Level III Advanced Trauma Facilities and 193 Level IV Basic Trauma Facilities.

He said that approximately 40 Texans die every day due to traumatic injuries, and for every one that dies, at least six are injured.

“We are 1.5 million people in our region, yet the nearest level one Trauma Center is over 240 miles away in Houston,” Cardenas said. “We thank you for passing the Resolution today.”

Cardenas added: “By having a Level I trauma center in our area, along with the UTRGV School of Medicine, it gives us the ability to train the next level of surgeons who will stay in our area.” 

Hidalgo County Commissioners passed a resolution in support.

Dr. Raul Barreda’s Perspective

Just before the legislative session ended, Dr. Raúl Barreda gave the Rio Grande Guardian an exclusive interview about DHR Health’s efforts to secure a Level 1 Trauma Center. He said that while the hospital system is technically at Level III status, it is functioning as though it is at Level 1.

Asked to define a trauma center, Barreda said: “A Trauma Center is an institution that has been verified and accredited by the American College of Surgeons and the Texas Department of State Health Services, as having the appropriate facilities and the appropriate staff to care for an acutely injured patient, as defined by a patient being included into a state trauma registry.

Barreda said functioning as a Level 1 Trauma Center is important to the overall care of the patient. 

“There are multiple clinical aspects but the initiative driven by the American College of Surgeons requires that the trauma patient be taken care of from the time they come in through the door until the time they leave. This is different to lower level trauma centers. You need specialists, such as orthopedic surgeons, orthopedic traumatologists, neurosurgeons, the rehab specialists, case managers and social workers. Any nurse that touches these patients on the floor, in the ER, in the operating room has different certifications and classes that they have to do to know.”

Barreda said the American College of Surgeons has noted that these patients have a better overall outcome if they are followed and taken care of throughout their entire stay by the trauma surgeon. 

“There is a continuity of care, there is a captain of the ship. So, the trauma surgeon initiates the care, the trauma surgeon involves all the specialists to make sure the right people are working with the patient for the right amount of time. The trauma surgeon arranges their rehab, the trauma surgeon arranges the medical supplies they need at home, the trauma surgeon follows up with that patient.”

Barreda said the American College of Surgeons knows that a huge difference exists between Level 1 and trauma levels below that. He gave the example of a highly unstable patient who has been ejected from a vehicle in a high speed motor accident.

“The victim may have a long hospital stay, an ICU stay, we have surgical ICU intensive taking care of him. Eventually they may need rehab, they may need braces, they may need other things going on. We arrange that.”

Another example Barreda gave is an elderly patient who falls off a chair and has a small pelvic fracture. 

“This could turn into a huge complication if not tended to correctly, surgically. Then a huge complication if not tended to on the hospital floor, then a huge complication if not tended to in the rehab process or tended to at home. All of those things are ideally prevented by having the traumatologist and a trauma surgeon following and caring for that patient. That is the initiative for having the overall care of these patients at the Level 1. That is why they call it a comprehensive Level 1 facility that is taking care of that patient.”

Barreda continued: “Functioning as a Level 1 center means we have to provide all of those services. And we have to provide those services for a minimum of 12 months. Then the American College of Surgeons and the State of Texas will come down and they will review all of our charts, they will see all of our outcomes and they will verify whether we are doing a good job. “Qualification for being a Level 1 trauma center is a huge deal but basically to get to that point you have to prove that you can do it. Nobody is going to hand you a certificate.”

Barreda said DHR Health has been planning to get to Level 1 since it first became a Level 4 trauma center. 

“We had a timeline of a couple of years at this level, moving over to this level (3). That has been our program. When we started talking about that we also talked about the entire community and where this plays into things. An example would be, we wanted our surgical residency and our GME to take foot and to be powerful before we even pushed for a Level 1. We wanted our surgical residents to be coming into their fifth year of training – their PGY5 – before we became a Level 1. We did not want to be running a Level 1 trauma center and have first year surgical residents in that situation. We wanted to make sure we could handle the residency and have good residents and good surgeons. Once we were confident with that we could move onto our next project.”

Barreda said that when looking at DHR Health’s surgical residents, he is proud of the product put out. 

“They are scoring extremely high on their tests. They are scoring extremely high on their surgical olympics. They are scoring extremely high when they go to outside hospitals on rotations. The experience they have at Doctors Hospital at Renaissance, as opposed to other residencies, is exceptional. So we now we have a good product there. We build on that.”

Asked why DHR Health wanted to jump from Level 3 to Level 1, bypassing Level 2, Barreda said:

“For us, the Level 2 would mean we are compromising in one way for the patient care. For a Level 2 and a Level 1 you have to have an orthopedic traumatologist to care for your trauma department. That is required for a Level 1. You have to have a surgeon-led surgical ICU. That is required for a Level 1. You have to have 250 patients a year with an ISS (injury severity score) score greater than 15. What that means is that you have to have the sickest of the sick, the most unstable, the highest level trauma patients. You have to have more than 250 a year. That is a requirement for a Level 1, not a Level 2.”

Barreda continued: “You are not going to be a good trauma center if you only get one big trauma a month. If you get five bad traumas a day you are going to be a pretty good trauma center. You get five bad traumas a day, when that elderly patient falls down from her chair, you are going to be able to take care of that one real good. You have seen all possible complications. You have all the experience to take care of those patients and you have the infrastructure in place.”

If DHR Health was going to go for a Level 1 Trauma Center designation, it would have to “pull the trigger and fix everything else across the board in the hospital,” Barreda said. “We would have to upgrade the ICU, upgrade the orthopedic department, upgrade the surgical department, upgrade the GME. Why stop just to make a check box. Go all the way.”

Asked how DHR Health would interact with other hospitals if it were a Level 1 Trauma Center, Barreda said:

“We want referrals from Kleberg County, we want referrals from Corpus, Falfurrias, Laredo. We want them coming to us. But, the way trauma systems work, is if there is a patient that is injured in Brownsville, that patient needs to go to the nearest capable center that can care for that patient. If that hospital has the proper person to take care of that patient and to save that life, that is where that patient goes. The purpose of the Level 1 is to be the referral center. They are also supposed to coordinate the care of all the trauma centers in the Valley. So, the Level 1 needs the Level 2, the 2 needs the 3 and we all work off each other. So, the patient that gets injured in Brownsville goes to the nearest Level 3, gets stabilized, they have saved the life at that point, then, if they need a higher level of care, they call us to transfer that patient to us and we continue the care to make sure, long term, that that patient has decreased morbidity and decreased complications. We are the referral center for all trauma centers. But, that patient needs to get somewhere in the 30 minutes or less.”

Asked if it was an easy sell to the DHR Health board of directors to go after a Level 1 Trauma Center designation, Barreda said:

“The DHR board is highly intelligent. There a lot of physicians on the board. When you are a physician-owned hospital, you get things done extremely quick. Everybody sees the vision, everybody sees the need, and most of those people treat people daily. So, they understand what is out there, they understand what is lacking. It is not one person who has to convince everybody. Hey, we need to do this. Hey, this is the right thing to do. That would take forever. When we have the orthopedics going, we have the head of the ICU going, we have the head of radiology there, we have the head of ER there, we have the head of anesthesia there, I am merely coordinating things. Every physician is driven to go down the same path we are going and when everybody says this is the right thing to and the board agrees, financially yes we can do it, that is what makes it easy.”

Barreda concluded the interview by stating the difference between a Level 1 Trauma Center and one operating rung below. He said it there is a lot more to it than just the capability to do research.

“The American College of Surgeons mandates certain things for certain trauma centers to be that level of credentialing. When they say that they require a Level 1 Trauma Center to have involvement in research and education it is for the purpose of having a different level of quality at that trauma center. An example would be, if I am going to be educating and teaching surgeons to become trauma surgeons and general surgeons. I may be a different level of surgeon at a trauma center because I am a professor. I am teaching other surgeons how to be surgeons. That is different than a person covering trauma at a Level 3 center, or a person covering trauma call at a Level 4 center. It is a different category, a different quality. That is why the American College of Surgeons said this has to be a teaching hospital, this has to have the education component. Now, all of a sudden, those trauma surgeons aren’t just somebody covering a call shift, they are educators. So, now they have to teach surgeons how to be care givers and scientists and think outside the box, and handle critical care, and take care of the sickest patients of every single trauma that there is because we have that requirement of those high ISS score patients going to that teaching hospital. That isn’t required at any other trauma center. So, it multiplies.”

At a Level 1 center, Barreda said, trauma surgeons have to teach care givers and scientists how to think outside the box.

“We are not just showing up to work, punching a clock, taking care of a patient and going home. We are showing up to work, getting in there and saying, okay, we saw three patients with the same injury, what is going on. Is there a seat belt issue going on, is there an on-ramp on the expressway issue going on, is there a nursing home issue going on. That is local research trying to prevent further trauma for a certain thing in your area. So, the highest number of trauma patients admitted to Lubbock may not be the highest number of trauma patients admitted to the Rio Grande Valley. It may be a different category of people. In North Dakota, they may have three snow-related mobile accidents a day. We don’t have snow mobile accidents in the Rio Grande Valley. Their research may be geared towards the prevention of snow mobile accidents. Our research may be geared towards, at what age is it safe to have a child in the front seat. How many people should occupy the back seat of a vehicle. We have to look at what our local population is getting injured from and tailor our research towards that.”