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DURHAM, N.C. - Duke University Hospital is placing trauma surgeons around the clock in its Trauma Center and has taken other steps to address issues raised by a state review team following a March site visit to consider Duke's request for renewal of its Level 1 trauma center status, hospital Chief Executive Officer Michael Israel said Monday.

A report by the state Office of Emergency Medical Services (EMS) said the Duke center's "strengths are diverse and numerous," but the team also cited five "deficiencies," prompting the EMS staff to recommend the Duke center be placed on probation for nine months to a year to provide time to meet the state's criteria for a Level 1 status.

Duke's request for renewal of its Level 1 Trauma Center status is scheduled go before the state EMS Advisory Council Tuesday at its regular quarterly meeting at N.C. State University. Duke has been a Level 1 center since 1982.

In a letter Monday to Drexdal Pratt, of the state Office of Emergency Medical Services, Israel urged the council to recommend that Duke receive recertification as a Level 1 center. He said Duke has addressed all five concerns raised by the review team.

"Given that the recommendation for probation is based solely on these areas of concern and the fact that Duke University Hospital has (or will by June 1, 2000) both met and demonstrated compliance with all issues raised, we ask the committee to consider recertification of the Duke Hospital trauma program as a Level 1 Center," Israel said.

Israel said Duke is currently spending $1.2 million to support the trauma program and is investing an additional $700,000 to meet the latest regulatory requirements cited by the review team, primarily in having the trauma surgeons on site at all times. He said this funding does not include the costs of serving indigent trauma patients.

"Because we are committed to the highest quality comprehensive trauma care and to the research that improves that care, we will commit the necessary funds as we believe that our patients and the communities we serve expect and deserve nothing less," he said. "However, as you can appreciate, such investments are becoming increasingly difficult during these times of rapidly diminishing reimbursements.

"In addition, the cost of trauma care is increasingly expensive as many of the trauma patients are uninsured, a fact that presents an additional financial burden for all trauma centers in North Carolina, especially private institutions. For example, in 1999, Duke Hospital lost nearly $750,000 providing trauma care for 472 Durham County residents alone, and these individuals represented only one-third of the total trauma patient population served at Duke Hospital.

"The state is performing its proper function in establishing guidelines for the operations of Trauma Center programs in North Carolina. At the same time, since the State of North Carolina has assumed these responsibilities, we believe it also has the responsibility to assume a portion of the burden of the costs for the provision of these services at all designated trauma centers in North Carolina. We look forward to working with all of the Trauma Centers in North Carolina to develop a program of financial support from the state to ensure the continuation of the level of trauma services that is appropriate for the citizens of the our state," Israel said.

North Carolina has nine trauma centers, five of which are designated as Level 1 centers, the highest of three levels based on medical specialists available and a variety of other criteria. In addition to Duke, the other Level 1 centers are Carolinas Medical Center in Charlotte, Wake Forest's Baptist Medical Center in Winston-Salem, the University Health System of Eastern Carolina in Greenville and University of North Carolina Hospitals in Chapel Hill. The UNC trauma center was placed on probation for up to a year following a site visit last December.

Level 2 centers are at Mission St. Joseph's Hospital in Asheville, New Hanover Regional Medical Center in Wilmington and WakeMed in Raleigh. Moses Cone Hospital in Greensboro recently withdrew its Level 2 designation under threat of having it revoked by the state. Cleveland Regional Medical Center in Shelby is a Level 3 center, and usually transfers its most serious cases to a Level 1 or 2 center.

One of the deficiencies listed by the state review of Duke's trauma center was that a trauma physician does not always respond within 20 minutes. Duke is correcting this by paying surgeons to be in the trauma center 24 hours a day, seven days a week.

The review team also found that an in-house anesthesiologist was not listed as part of the trauma team. The in-house anesthesiologist now responds to trauma team activation.

The review team also found that an appropriate in-house post-graduate or senior surgical resident did not respond within 20 minutes. The addition of in-house trauma surgeons corrected that problem. A fourth issue was that four of 15 emergency physicians did not have the required 20 hours of continuing medical education. Duke officials said the physicians have been counseled and already have completed the training.

The fifth issue was that there was not a back-up trauma surgeon schedule posted. Israel said a schedule is now posted in the emergency department and operating room.