Article 1
Surgical stabilization of critical abdominal injuries in a mature rural trauma system: A Retrospective Study. Tinsman C, Lilienthal M, Galet C, Torner J, Skeete DA. J Trauma Acute Care Surg. 2023 Feb 1;94(2):248-257.
Trauma patients from rural areas experienced worse outcomes compared to their urban counterpart. This can be attributed to distance to hospitals, transport times and fewer facilities capable of handling complex trauma cases. Iowa has the 12th highest percentage of population living in rural areas at 36% with 2 ACS-verified Level I Adult Trauma and 1 Level I Pediatric Trauma Center; 3 ACS-verified Level II (2 adult and 1 pediatric); and one ACS-verified Level III and 12 state-verified Level III and 101 Level IV. The Iowa’s out-of-hospital triage guidelines recommended that EMS transport patients to nearest Level III or IV if transport to Level I or II is more than 30 minutes.
With the availability of general surgical coverage at Level III and IV trauma centers, injured patients can undergo stabilization and resuscitation including abdominal explorations and damage control operations. In 2015, the state consulted with American College of Surgeons Committee of Trauma and recommendations were made including the use of ACS 2014 verification criteria and changing of state verification to ACS verification of Level II trauma centers. This retrospective study aims to evaluate the proportion of damage control laparotomies as well as transfusion practices comparing this group with patients who underwent laparotomy within 4 hours after arrival to accepting facility and compare their outcomes from January 1, 2010 to December 31, 2020. This study included 213 patients (out of state patients and non-emergent laparotomy were excluded). Pre-consultation period (2010-2015) with 106 patients was compared with ACS Post- consultation period (2-016-2020) with 107 patients.
There are similar proportions of laparotomies before and after transfers between the pre-consultation and post-consultation periods but when patients were categorized based on severity of abdominal injury, there was a significant increase in proportion of laparotomy from the referring hospital during the post-consultation period. Laparotomies are done mostly at Level III trauma centers. They are more likely to perform laparotomy prior to transfer (74.3% vs 53.6%, p=0.007) after ACS post-consultation. There was an increase of blood product administration at referring hospitals with significant increase in administration of plasma and platelets. Procedures performed during the initial laparotomy included packing (22.1%), bowel resection (19.7%), splenectomy (17.4%), organ repair (hepatorrhaphy, splenorrhaphy, and/or bladder repair) (17.4%), repair of intestinal injury (11.3%), vascular ligation (2.8%), and other procedures (7%).
Post-consultation, patients who underwent laparotomy at the referring hospital spent significantly less time at the referring hospital and had shorter transport times to a Level I facility when compared with patients who underwent surgery before transfer in the pre-consultation period.
Development of inclusive trauma system helped ameliorate the delivery of appropriate care to injured rural patients by quick and efficient identification of injury and surgical stabilization and resuscitation and expedited transfer to Level I trauma centers. The 2015 ACS Committee on Trauma consultation visit helped increase the proportion of referring hospitals providing surgical stabilization for patients with higher shock index and severe abdominal injuries by increased use of damage control laparotomy. There was no increase mortality with surgical stabilization at the non-Level I trauma centers. As the trauma system matures, Level III hospitals are performing more laparotomies after the ACS- COT consultation period. Development and refinement of triage protocols, trauma education, transfer agreement, referral systems and workflows occurred during this maturation process. Though this is a retrospective study with its inherent limitation, this can be a template or model for other states with similar disparities in trauma care in rural areas.
Article 2
Impact of Tele-Triage Pathways on Short-Stay Admission after Transfer to a Regional Burn Center for Acute Burn Injury. Clark NM, Agoubi LL, Gibbs S, Stewart BT, De Grauw X, Vavilala MS, Rivara FP, Arbabi S, Pham TN. Journal of American College of Surgeons. 2023 Sep 11.
United States has a highly regionalized burn care and treatment thru American Burn Association-verified burn center. Early transfer to burn centers improves outcome but also lead to over- triage resulting in short stay admissions defined as discharges within 24 – 72 hours. In 2016, University of Washington implemented a burn tele-triage system to reduce short stay admissions, facilitate a more accurate assessment of the size and severity of burn and prioritize in patient care for higher burn severity. This retrospective study was conducted to compare all transferred burn patients pre-implementation (2010-2015) and post-implementation (2017-2019) of tele- triage system.
Four-tiered tele-triage pathways were implemented which include: Green pathway – low acuity injuries amenable to direct outpatient referral without immediate involvement of burn provider; Blue – low acuity with potential for local care and discharge; Red – low acuity injuries where consulting provider request transfer and Black pathways requiring rapid transfer. Transfer nurses received training and utilized standardized reporting.
Short stay admission decreased from 50% to 39% after implementation of the tele-triage. Post-implementation, patients were 17% less likely to have short stay admission. Higher proportion of patients underwent burn excision (19.1% vs 15.9%) with longer length of stay during the post-implementation period suggesting higher severity of injuries among patients transferred. Pediatric patients (less than 15 yr.) were most likely than adult patients to have short stay admission which account for 43% of transfers resulting in 2.4x higher likelihood of short stay admissions. This can be ameliorated by increasing local capacity for management of minor pediatric burns.
Based on this study, tele-triage burns transfer protocols reduced short stay admissions, potentially avoiding over-triage leading to over transfer and helped the burn centers prioritize patients with more severe injuries. Aside from better healthcare utilization, this might also prevent burn out among providers. Tele-triage can potentially be used in trauma and even other surgical and medical conditions to prevent unnecessary transfers and optimize the limited resources to those that needed the specialty care. Outside of the scope of this study, under-triage and under- treatment of burns from tele-triage system should be measured in future study. Other topics to explore are cost savings from potential transport cost, unnecessary use of the specialty care as well as the provider and patient satisfaction. Adoption of technology proved to be effective in triaging burn injuries and potentially can be applied to other injuries as well as medical and surgical conditions to optimize limited health care resources.
