Trauma Center Feasibility in Rural Areas

South Carolina

South Carolina is home to over 5 million people. Five adult Level I trauma centers and two Level II adult trauma centers serve thousands of patients in the metropolitan regions, as well as patients transferred by ground or air from rural areas of the state. But when transport between the scene of injury and higher-level trauma care is delayed by distance or weather, chances of survival decrease. Many states have adopted Level IV trauma centers in rural areas to ensure that patients injured in these regions can be immediately stabilized and quickly transported to higher levels of care. At the time of the project, the state of South Carolina had a single Level IV trauma center. Other small critical access hospitals were interested in understanding the clinical and financial feasibility of becoming a Level IV facility but were unsure if they could meet the readiness requirements, afford the trauma program, or further burden their already strained workforces.

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Collaborative, Data-Driven Approach

The consultants were tasked with three key objectives:

Perform a market and financial analysis for five rural hospitals in South Carolina to predict potential Level IV trauma volume
Review Level IV trauma center criteria with each hospital and estimate trauma readiness costs
Evaluate if the Level IV trauma center would have a sufficient volume and payor mix to be financially sustainable

To estimate the number of patients injured in each hospital’s catchment area, the consultants reviewed hospital patient and financial data, as well as emergency medical services (EMS) data from the South Carolina Department of Health & Environmental Control. The consultants also met with hospital representatives to review requirements and to discuss their ability to add a Level IV program.

Key Findings

Hospitals Already Saw Injured Patients

Rural hospital were already evaluating and treating injured patients, who were then discharged home or transferred to a higher level of care.
New incremental volumes were not significant, meaning that most injured patients in the regions were already receiving initial assessment at the rural hospitals.

Hospitals Would Break Even

After factoring in new costs for Level IV trauma readiness, payor mixes exceeding 50% Medicaid, and potential use of 068x trauma charges, most Level IV trauma centers would break even or generate a negligible profit on their trauma program.

Hospitals Could Formalize Trauma Care

Formalizing a hospital’s status as a Level IV trauma center could improve quality of care for these patients and bring recognition for the work they are already doing.
There are program costs associated with operating a trauma center, but trauma activation charges could cover some of those new costs.

Community Impact

The consultants delivered final reports to each of the participating hospitals and met with hospital CEOs to answer questions. This provided a chance to educate rural hospital leaders on the requirements of trauma care and listen to their concerns about meeting the needs of injured patients in their regions.

While participating hospitals were interested in the potential pursuit of Level IV trauma status and appreciated the importance of these facilities in their state, their concerns reflected the major challenges in rural healthcare:

At the time of the analysis, these distressed facilities were dealing with a new surge in the COVID pandemic and leaders were hesitant to add any new burden to their already strained workforces
Even though Level IV trauma center requirements are minimal, rural facility leaders were concerned about ongoing and affordable access to trauma education requirements (e.g., ATLS, TNCC), garnering active trauma committee participation from physicians, and maintaining hospital resources and program quality over time
Hospitals were concerned about increased volumes or receiving critically ill patients that should have been flown to a higher level of care directly from the scene of injury
Hospitals expressed that they would be more likely to consider Level IV status if they were in a collaborative with other hospitals that provided a coordinated and streamlined approach

A modifiable spreadsheet template was available to participating hospitals so they could consider different volume and payor mix scenarios and see the results on expenses and revenue. The financial assessment tools and framework have since been used by other rural hospitals in the state and aided a hospital in eastern South Carolina when it became the state’s second level IV center.

"Rural hospital leaders want to provide every service their community needs, but it can’t be done without appropriate financial support. The consultants listened to the needs of the hospitals, provided sound recommendations, and gave leadership confidence in the path going forward, whichever way that path led. Their positive impact has continued for years beyond the project's conclusion.”

Britton Herbert

Director of Data Strategy & Healthcare Integration
South Carolina Office of Rural Health