Two reports last month on how rural area hospitals handle trauma indicate there's lots of low-hanging fruit for providers who want to improve trauma care and save more lives.
Both studies published in the Journal of Trauma give a stronger voice to those who say we need to have better trauma coverage across the country, because many lives of many people, a significant portion of whom are young, productive workers, could be saved.
Both studies imply that better transfer arrangements from hospitals and providers with limited skills and resources to certified trauma centers is essential.
The first study, "Identifying Targets for Potential Interventions to Reduce Rural Trauma Deaths: A Population Based Analysis," looked at 3,486 trauma deaths in the largely rural province of Ontario, Canada between 2002 and 2003.
David Gomez, MD, and collaborators at St. Michael's Hospital in the University of Toronto, found that a significant portion of these deaths occurred not on the way to the hospital, but in a rural hospital's emergency room. In other words, these victims managed to survive the distance to the hospital but when they got there, the hospital was unable to save them.
"This study provides new insights in to rural trauma deaths and suggests the potential value of targeted interventions at the policy and provider levels to improve the delivery of preliminary trauma care in rural environments."
The authors wrote that many practices, cultures, and circumstances in rural areas might have led to these injuries, including a lower rate of the use of protective devices, crashes of motor vehicles going at higher speeds on rural roads, higher prevalence of alcohol while driving, and longer times between the injury's occurrence and its discovery.
In Ontario, all eight trauma centers have a Level 1 designation, the authors wrote. Thus, "there is no minimal standard of preparation or skills to assure the optimal preliminary care of the injured patient" except these centers. Inclusive systems, where all centers participate in trauma care to the extent that their resources allow, provide lower levels of trauma center designation (Level III and IV) and are associated with a lower risk of injury-related mortality."
Also, they said, the skill set of emergency physicians in rural areas is variable, with very limited exposure to severely injured patients. "There is no requirement for ATLS (Advanced Trauma Life Support) certification in the region."
While the majority of deaths occurred in the field, before any hospital contact, the authors wrote, only 15% of the population lived beyond 1 hour of a trauma center. Yet residents of these areas "accounted for 37% of all trauma-related deaths over this time interval."
The report added that prevention strategies for vehicular crashes, such as automatic crash notification technology, might speed discovery time. Another effort to improve outcome would be through investments in transportation and paramedic resources "to minimize time to inter-facility transfer."
The second study, "Scoop and Run to the Trauma Center or Stay and Play at the Local Hospital: Hospital Transfer's Effect on Mortality," by researchers in Salt Lake City, Seattle, Denver, Pittsburgh and Dallas, drew a similar conclusion. Ram Nirula, MD, associate professor of surgery at the University of Utah, found that the odds of death were 3.8 times greater when matched patients with similar injuries were initially triaged to a non-trauma facility.
"Triaging severely injured patients to hospitals that are incapable of providing definitive care is associated with increased mortality," they wrote. "Attempts at initial stabilization at a non-trauma center may be harmful."
Their report looked at 1,105 patients admitted to eight participating institutions between April, 2004 and June of 2007 who had endured a blunt trauma, and arrived at a hospital within six hours. Patients who first went to a non-trauma center hospital and were then transferred to a trauma center were compared with those who were directly transported to a Level I trauma center.
"There seems to be less aggressive resuscitation when inter-hospital transferred patients arrive at the trauma center, despite similar ISS (Injury Severity Scores) between these patients and those going directly to the trauma center from the scene," the authors wrote.
The authors aren't sure why, but hypothesize that resuscitation efforts related to the transfer, and subsequent trauma team management.
"If the time from the field to the closest hospital is not significantly longer than the time to the nearest trauma center that can deliver definitive care, it may be beneficial to bypass the closest hospital in light of improved pre-hospital care," they wrote.
The Affordable Care Act calls for increased spending and attention to providing trauma care in rural areas, although those appropriations may be in jeopardy because of funding limitations. Of course we can't build Level 1 trauma centers to cover the entire country. But a more sensitive appreciation of the limited capabilities of some rural emergency rooms, and better triaging to better equipped trauma centers, may ultimately save more lives.