Summary: This retrospective study used the Pennsylvania Trauma Outcomes Study (PTOS) registry to examine pre-hospital triage patterns in rural vs urban injury locations over a period of 17 years. Rural vs Urban designations were designated at the county level and considered urban if the density was greater than this overall state population density. The primary outcome measure was under triage. Triage in the setting of this paper represents prehospital identification of patients with the potential for severe injuries and direction to an appropriate level of care – usually a level 1 or 2 trauma center. Triage decisions were analyzed using the National Field Triage Guidelines developed by the American College of Surgeons. Patients were considered under triaged if they met any of the anatomical of physiologic criteria for high risk of serious injury and were not transported directly to a level 1 or 2 trauma center. Under triage was assessed for an association with in-hospital mortality and then for its association with rural vs urban settings and transport times.
This paper demonstrates under triage is associated with higher mortality and under triage is more common in rural settings (8.6% vs. 3.4%; p < 0.01). Under triaged patients also had lengthier pre-hospital transports, both in time and distance (miles). A subgroup analysis demonstrated a pattern of crush injuries, penetrating injuries, and GCS 13 or less being associated with under triage in rural counties. When examining only rural patients, rural setting of injury was not associated with under triage if the patient was treated at a rural trauma center or transported by helicopter.
Review: This paper correctly acknowledges its limitations as a retrospective review; within that limitation is the inability to evaluate the rationale of individual pre-hospital providers. Additionally, the binary association or rural vs urban may represent an oversimplification of the state geography. I suspect this may actually dilute the impact of truly remote communities. Overall, the paper has a robust primary and subgroup analysis that demonstrates the importance of our rural trauma centers. The results support the importance of continued education and outreach with pre-hospital providers, particularly in countries where transport times are lengthy. Education on when to bypass the closest hospital facility and proceed directly to a higher-level trauma center should be emphasized when training pre-hospital providers working in these rural regions and may reduce mortality. While expanding and/or maintaining rural trauma centers can be challenging, increasing rural community access to helicopter transport may be a more feasible method to reduce under triage and mortality according to this analysis.
This was a retrospective analysis using TQIP database from 2017-2021 evaluating the use of REBOA in adult patients meeting all the following criteria: penetrating (GSW or stab) abdominal trauma, shock (SBP ≤90), and undergoing emergent laparotomy. Majority of patients in both groups were young, nonwhite males with a GSW as the penetrating mechanism. REBOA group was noted to present with a lower mean SBP and a high proportion of severe (AIS ≥4) abdominal injuries. Outcomes included time to incision, transfusion requirements, complications, and in-hospital mortality along with a 30-day survival analysis stratified by presenting SBP. In comparison to previous REBOA analyses, these authors focused only on penetrating injuries (not mixed mechanisms), definitive treatment being laparotomy, and did not use REBOA registries as their source without a control group. Simply, REBOA was used as a bridge in attempt to reach the OR.
With propensity score matching (2:1), a cohort of 148 REBOA vs 280 controls were analyzed. Study excluded patients who did not make it to the OR for a laparotomy as well as any ED deaths. They found an increased mortality risk with REBOA vs no REBOA (53.4% vs 42.5%) along with an increased 30-day mortality (HR 1.34), with an even worse survival for the subgroup with SBP ≤70. Within the first four hours REBOA was associated with greater utilization of blood products (~5.1/L vs 2.9L; REBOA vs no REBOA). There was also increased time to incision in REBOA group (40 mins vs 31 mins) and increased complications such as extremity compartment syndrome and need for amputation (4.1% vs 0.4%; 3.4% vs 0.4%). Interestingly, when matching a subgroup with GCS motor of 6, there was no statistically significant mortality difference, although there were increased transfusion requirements in REBOA group.
This study does a nice job highlighting a very relevant cohort with strong propensity matching and meaningful outcomes. Of course, there is room for selection bias as this study only included patients who made it to the OR. In addition, there is no data on occlusion time, whether partial or complete occlusion was used, or which what zone. Prior REBOA studies have suggested that a SBP between 60-80 mmHg led to a more favorable outcome. Here, we can see that a matched cohort SBP ≤70 had worse outcomes with REBOA vs straight to OR. One could still possibly justify the efficacious use of REBOA in non-compressible pelvic hemorrhage, patients not immediately operable or as a bridge in more austere environments. However, for penetrating abdominal trauma presenting in shock- proceed immediately to the OR, do not delay definitive control.
Summary: The Rural Trauma Team Development course (RTTDC) was created in 1998 to provide training for personnel at rural facilities in order to improve initial patient care and strengthen the relationship with their regional trauma center. Objective analysis of the impact of the RTTDC on patient outcomes and achieving its goals (stabilize, recognize need for transfer and avoid unnecessary imaging that may delay transfer) was undertaken to evaluate the impact of the training. Between 2015 and 2021, RTTDC was taught at 16 hospitals in Nebraska and western Iowa. Their regional trauma center (University of Nebraska Medical Center in Omaha, a Level I trauma center) compared patients who were transferred from these 16 facilities before and after RTTDC implementation. They compared several key outcomes- ED dwell time, time to decision to transfer, number of plain films and CT scans obtained before transfer, and mortality. 472 patients transferred (240 pre-RTTDC and 232 post-RTTDC). Patients in the pre-implementation and post-implementation were similar, including a similar age and gender. Notably, they also had a similar median ISS, so there wasn’t a shift toward less injured patients in the post-implementation. Following RTTDC training, there was a significantly decreased average ED dwell time and time to decision to transfer, both occurring about 1 hour sooner. There were also fewer radiographic images (2.8à 2.2) and CT scans (1.6à 1.2) obtained before transfer. There was no difference in mortality.
Review: Education is a vital component of improving patient care, and RTTDC is designed to leverage the role of the rural facility in the trauma chain of survival. Significantly shorter ED dwell time and expedited decision to transfer are direct objective measures of the impact of this training. Although there was no difference in mortality, this shouldn’t be considered as an indicator that the training isn’t worthwhile. Mortality is multifactorial, and mortality rate isn’t a direct indicator of the impact of the training. More rapid decision to transfer is easily measurable, and a good indicator of the impact of the training.
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