March 2023 - Rural Trauma

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Article 1 reviewed by Natalie Hodges, MD, MPH and Ariel P. Santos, MD, MPH, FACS, FCCM
Trauma transfers discharged from the emergency department—Is there a role for telemedicine? Lindsey LJ, Rasmussen LS, Hendrickson LS, Frech ES, Bozell SP, Stewart KE, Kennedy RO, Cross A, Albrecht RM, Celii AM. J Trauma Acute Care Surg. 2022 Apr 1;92(4):656-663.

Article 2 reviewed by Natalie Hodges, MD, MPH and Ariel P. Santos, MD, MPH, FACS, FCCM
Feasibility and Acceptance of a Teletrauma Surgery Consult Service to Rural and Community Hospitals: A Pilot Study. Kamine TH, Siu M, Kramer KZ, Alouidor R, Kelly E, Deutsch A, Mader TJ, Visintainer P, Grochowski K, Jabbour N. J Am Coll Surg. 2023 Jan 1;236(1):145-153.

Article 1
Trauma transfers discharged from the emergency department—Is there a role for telemedicine? Lindsey LJ, Rasmussen LS, Hendrickson LS, Frech ES, Bozell SP, Stewart KE, Kennedy RO, Cross A, Albrecht RM, Celii AM. J Trauma Acute Care Surg. 2022 Apr 1;92(4):656-663.

Patients injured in rural areas are commonly transferred to higher level centers, a well-established mechanism in most trauma systems based on triage system. Rural trauma patients are more likely to have complications and 50% more likely to die as compared to their urban counterparts.  Most trauma systems are overextended at baseline, and overuse impacts resource availability. Telemedicine is a burgeoning clinical pathway, especially as its broader application was demonstrated in the COVID-19 pandemic. However, a clear role for and efficacy of telemedicine in trauma patients has not yet been established, specifically the factors that predict which patients will most benefit from telemedicine as opposed to transfer to a higher level of care. In this study, the authors employed a single center retrospective review to identify potentially inappropriate transfers. The primary outcome measure was inappropriate transfers based on direct discharge home from the trauma bay after transfer for higher level of care. Secondary outcome measures included characteristics of patients who may benefit from a telemedicine consult (i.e., inappropriately transferred patients) and the financial implications in decreasing inappropriately transferred patients. The authors identified 2350 total patients transferred to the Level 1 trauma center in Oklahoma City. Of these, 27% were discharged directly home from the ED. There was an expected trend toward increased likelihood of discharge from the trauma bay with decreasing trauma level of activation. Of discharged patients, 36% required a bedside intervention only-of which laceration repair, ophthalmology evaluation, splint application and fracture/dislocation reduction were most common. Of patients discharged without any procedures (64% of 632), the most common injuries were facial injury (35%), ortho/hand injury (17%), soft tissue injury (16%), spine injury (10%), head injury (7%), penetrating (3%), rib fractures/chest wall contusions (3%), solid organ injury (0.5%), and burns (0.5%). In addition, 7% of transferred patients had no significant injury. The authors identified 13% of transferred patients (310/2350) that could have benefitted from telemedicine consultation with the tertiary center without the need for transfer. This study also elucidated financial implications of transferring patients. Of transferred patients, 72% were transported via ground ambulance, and 20% were transferred via helicopter ambulance. The average length of transfer among the 10 most common transferring facilities was 63 miles with average time of 64 minutes. The average cost of transfer per patient was $1000 for ground and $40,000 for air transfer, which would result in a savings of $239,000 ground cost and 1.36 million in air costs if all inappropriate transfers were avoided not including the costs incurred after discharge.

It was suggested by the authors the use of an existing trauma outreach system to create a standard telemedicine consult protocol starting with centers that transfer the highest volume of patients. Telemedicine consult could potentially offer cost savings while still allowing for subspecialty consult and for triage by specialists familiar with specific injuries. This could be a strategy for resource-savings across the trauma systems to reduce transfers without a negative impact on patient care. Telemedicine can potentially improve the quality, cost and timing of care for rural trauma patients, and with proper guidance from the Level 1 trauma centers, appropriate transfer can be ensured thus avoiding over and under triaging. This can also improve communication and education as well as build up confidence in  rural health providers who do not have much experience in managing trauma patients.

Article 2
Feasibility and Acceptance of a Teletrauma Surgery Consult Service to Rural and Community Hospitals: A Pilot Study. Kamine TH, Siu M, Kramer KZ, Alouidor R, Kelly E, Deutsch A, Mader TJ, Visintainer P, Grochowski K, Jabbour N. J Am Coll Surg. 2023 Jan 1;236(1):145-153.

Transfer of trauma patients is a well-established mechanism of escalation of care and broadening access to subspecialty care. However, ‘over transferring’ can result in overuse of resources without improvement in patient care. It is possible that patients can be discharged home or admitted to the referring rural or community hospitals under the guidance of Level 1 acute care surgeons, therefore obviating the need for transfer. In the wake of COVID-19 and increased use of telemedicine, there could be a role for telemedicine in reducing transfers of trauma patients and for monitoring them remotely. However, provider acceptance of teletrauma consultations is not well studied. This prospective pilot study examined 3 transferring rural and community hospitals to one Level 1 trauma center belonging to the same health care system and sharing the same electronic health records (EHR). All trauma patients with proposed transfer to the level one center were evaluated via telemedicine by a trauma surgeon at the Level 1 trauma center. After the intervention, referring providers were given a Likert-scale based survey to evaluate acceptance of the intervention, while trauma surgeons were given a NASA Task Load Index survey to evaluate changes in mental and physical workload. All patients who did not meet trauma activation criteria or require procedural intervention but deemed as transfer candidates were included.

21 patients were ultimately included for analysis that came from the three referring centers included in the study. Rib fractures were the most common diagnosis (57%) followed by intracranial hemorrhage (33%). Mean injury severity score was 7.9, and all but one patient had an initial Glasgow Coma Score of 15. No patients were hypotensive and only two were tachycardic on presentation. Nearly half (10 patients, 48%) of the included patients remained at the referring center, with 6 being discharged home and 4 being admitted under the hospitalist service at these centers. Remaining patients (11/21, 52%) were transferred to the Level 1 trauma center under medical service (2/21, 9.5%) and nine patients (9/21, 43%) directly admitted to the surgical service bypassing the ED. There were no significant differences in emergency department or hospital length of stay in transferred or non-transferred groups. There were no missed injuries or complications identified on post-discharge follow up. Emergency providers reported high levels of satisfaction with the teletrauma consult system relating to patient care and use of virtual technology. Additionally, trauma surgeons at the Level 1 trauma center reported low-moderate levels of demand using the NASA-TLX survey. This study though small ultimately showed that teletrauma consult could be of value in preventing over transfer of trauma patients without negatively impacting patient care. In this study, Teletrauma consults prevented a significant number of patients (48%) from unnecessary transfer, moreover, the results of both surveys demonstrated the feasibility and acceptability of teletrauma consultation service among providers. The positive results of this small-scale study ought to encourage consideration for broader implementation of Teletrauma consultations across larger health care systems to help decrease unnecessary patient transfer and to potentially reduce health care cost.