Quantifying geographic barriers to trauma care: Urban-rural variation in prehospital mortality. Jarman MP, Hashmi Z, Zerhouni Y, Udyavar R, Newgard C, Salim A, Haider AH. J Trauma Acute Care Surg. 2019 Jul;87(1):173-180.
Adequate access to trauma care is commonly measured by the time from injury to hospital presentation. However multiple populations including suburban patients, have been shown to have increased mortality rates despite timely access to care. Additionally, studies showing improved survival with timely access to care have thus far not included pre-hospital mortality data, potentially underestimating the true incidence of trauma mortality. To help better estimate trauma mortality, Jarman and colleagues used national epidemiological data from the CDC and the National Center for Health Statistics urban/rural county classifications (ranging from large, central metropolitan to non-core counties) to calculate county specific incidence rate ratios (IRR) of pre-hospital trauma mortality per 100,000 person-years from 1999-2006.
They found that as county classification progressed from most urban to most rural, the incidence of pre-hospital mortality increased. This coincided with a decrease in the percentage of counties without access to any trauma center within the county or in adjacent counties. Non-core counties, or counties with less than 10,000 people, demonstrated the largest increase in pre-hospital mortality over large, central metropolitan counties with an IRR of 1.6 after adjusting for socioeconomic factors; only 34% of these counties had access to a trauma center. Even “fringe” metropolitan counties, or those with over 1,000,000 people, had an IRR of 1.3 relative to large central metropolitan counties, despite 87% of these counties having access to trauma centers. These differences were especially pronounced in motor vehicle trauma with fringe metropolitan counties and non-core counties having an IRR of 1.8 and 2.7, respectively. These results demonstrate the significance of pre-hospital mortality even in areas with timely access to trauma care, and the importance of pre-hospital data in future studies of trauma mortality and access to care.Article 2Evaluation of trauma resources in rural northern Alberta identifies opportunities for improvement.
Jiang HY, MacLean A, Yoon J, Hughes S, Kim MJ, Anantha RV, Widder SL; Edmonton Zone Trauma and Acute Care Collaborative (EZ-TRACC). Can J Surg.
2020 Aug 28;63(5): E383-E390.
Rural trauma patients have a higher risk of mortality than urban patients due to delays in care, lack of specialty care, and limited pre-hospital and in-hospital resources. In Alberta, Canada almost one quarter of the population lives in rural areas with many of them spread out over an area larger than California. This leaves many without timely access to trauma care, especially to level 1 or 2 centers. In order to evaluate areas of need or potential improvement for rural trauma hospitals, Jiang and colleagues serially delivered a 49-question survey over 1.5 years to 50 rural trauma hospitals (Level 4 or 5) in Alberta; they received a 100% survey response rate.
They found that rural trauma hospitals had a median of 2 ambulances for air or land and a median of 7 emergency department (ED) beds. 56% of these EDs had adequate nursing coverage at the start of the study and this increased to 78% by the end of the study. Only 36% of hospitals had ED physicians with advanced trauma life support (ATLS) certification and 54% had trauma certified ED nurses. In terms of equipment availability, 74% had tourniquets, 70% had ultrasounds, 66% had rapid infusion warmers, and 66% had surgical equipment in the ED. There was central and peripheral vascular access equipment in 98%, and trauma resuscitation rooms in 94%, but 44% had inadequate amounts of blood product, 34% did not have 24-hour access to a blood bank, and only 22% had massive transfusion protocols in place. 24-hour access to board-certified radiologists or CT scanners was available in only 32% and 20%, respectively. As an adjunct, all centers had telehealth available (including 60% with tele-radiology), but this was not available in the trauma room for emergent consultations at the time of the study. Overall, this study has given valuable insight into the available resources and specific limitations of many rural hospitals. Serial surveys successfully identified and monitored improvements in resource availability over the course of the study, making it a potentially valuable tool for quality improvement at other rural centers.Article 3The geriatric trauma patient: A neglected individual in a mature trauma system.
Horst MA, Morgan ME, Vernon TM, Bradburn EH, Cook AD, Shtayyeh T, D'Andrea L, Rogers FB. J Trauma Acute Care Surg.
The increasing geriatric (age>65 years) population has resulted in a significant shift in geriatric trauma patients. Despite this shift, undertriage of injured older trauma patients continues. It is hypothesized that decreased access to trauma center (TC) care, and increased care at non-trauma centers (NTC) results in an underestimate of true geriatric trauma numbers. This study explored the rates of undertriage (UTR) in a mature trauma system and assess the role of NTCs in UTR.
This retrospective analysis used two databases to capture injured patients in the state of Pennsylvania, which has a mature trauma system. Using the state registry of inpatient admissions, injured patients with ISS>9 were identified using ICD9 coding and combined with data from the state trauma registry. UTR was calculated for each zip code area by subtracting number of patients cared for at a TC from those cared for at a NTC divided by NTC as well as a spatial empirical Bayesian method. The lower quartile, middle box, and upper quartile, for UTR were mapped at zip code area level and location of TC within map identified. The state inpatient registry contained 111,626 injured patients with ISS>9, which the state trauma registry contained 58,336 patients. This calculates as a statewide UTR of 47.7%, the lower quartile of UTR was less than 38.2%, and upper quartile greater than 60.1%. Lower quartile regions had highest population density, as well as TC density. There was an association with UTR and the type of nearest hospital (TC vs NTC), especially in larger NTCs.
This study demonstrates the effect of geography on UTR in geriatric trauma patients. Those in close proximity to a TC were more likely to present to a TC. Despite Pennsylvania have a mature trauma system, the rate of undertriage in these vulnerable patients remains high. Limitations of this study include a lack of outcome, as the inpatient admissions database does not contain clinical data. There is also no data on the reason for UTR (lack of protocol, patient preference, unrecognized severity of injury). Despite these limitations, the continued lack of access for injured older adults in clear. Geographic considerations as well as prehospital triage protocols are targets for improving access to care for geriatric trauma patients.
"Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico. Carroll AL, Garcia D, Cassells SJ, Bruce JS, Bereknyei Merrell S, Schillinger E. Cureus. 2020 Oct 24;12(10):e11143.
Individuals living in rural states or counties, particularly in the western United States, have decreased access to healthcare in general, and trauma care in particular. Long travel times as well as under-resourced critical access hospitals results in these patients succumbing to their injuries more frequently than urban patients. This mixed-methods study aimed to develop a conceptual framework that describes rural trauma care by combining geospatial analysis of trauma fatalities, trauma center location, and semi-structure interviews with emergency care physicians.
This retrospective study used the state health department information as well as the CDC Web-based Injury Statistics Query and Reporting System (WISQARS) to extract trauma fatality outcomes and note the average yearly fatality per 100,00 population in each zip code. This data was mapped in combination with the location of level I-III trauma centers, as well as approximate travel time to a trauma center. Additionally, 10 semi-structured interviews exploring 5 topic areas were completed with 5 New Mexico physicians and 5 out of state physicians with experience in rural emergency care. The geospatial analysis demonstrated 31.4% of the population lived in a county with >1 hour drive time to any trauma center, and 64.1% lived >1 hour drive from the state’s only level I trauma center. Comparing the state department of health data with the WISQARS data, there were contradictory results in the likelihood of death compared with distance to trauma center. The physician interviews revealed several thematic elements that result in poor rural trauma patient outcomes, which were used to create the conceptual framework. 1) Insufficient resources; including limited inpatient beds, lack of protocols, shortages and turnover of personnel. 2) Distance from trauma care; including travel time, incomplete data for research and quality improvement. 3) System-level deficiencies; including complex patient transfers, insurance, EMS absence or variation, and inadequate resource allocation.
This study provides an initial attempt at describing the systematic problems rural trauma patients face in accessing care, as well as the healthcare providers experience caring for injured patients. The initial conceptual framework provides a jumping off point for those interested in improving rural trauma care. This study is limited by the data sources as evidenced by opposite results using the national fatality data compared with the statewide data. Additionally, there is potential sampling bias in the selected interview participants. New Mexico is a very rural state with a small population which may limit the generalizability of the conceptual framework. However, this is an excellent first step in approaching rural trauma care in a systematic way that takes provider experience into account.