Rural Trauma Care Can, Should Be Better

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.