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Tertiary trauma care in a rural state
Tertiary Trauma Care in a Rural State J o h n B. C o n e , MD, Little Rock, Arkansas
T r a u m a patients in rural areas usually have no access to regional trauma systems or designated traun m centers. Efforts to provide quality trauma care in small hospitals m a y seriously overextend local capabilities. T h e urban trauma center retains an i m p o r t a n t role in trauma care even when the initial care must be p r o v i d e d at the local level. Twenty-five t r a u m a patients were transferred to University Hospital b e t w e e n 1 9 8 5 and 1 9 8 8 after definitive care was initiated in c o m m u n i t y hospitals. During the s a m e t i m e period, a total of 1 4 7 trauma patients were transferred to the trauma service. No i n f o r m a t i o n was available o n the total incidence of trauma. Medical records were reviewed to determine the reasons for transfer. Major reasons included the need for further complex surgery, better critical care support, and inadequate blood banks. T r a u m a centers serving rural areas provide a valuable resource well beyond the initial 2 4 hours.
omprehensive regional trauma systems reduce mortality after injury [I]. Despite the acceptance of this fact, the rural population of this country rarely has access to such care. Injury in a rural region has a disproportionately high mortality [2] even after entry into the medical care system [3]. Most discussions of this problem focus on local stabilization and rapid transfer to a trauma center [4]. For many reasons, this is often not feasible. Thus, the burden of trauma care falls on the community hospital and general surgeon. Rinker and Sabo [5] have recently reviewed trauma care from this perspective. This retrospective review was undertaken to clarify the role of the urban trauma center in providing tertiary support for rural community trauma care.
C
From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Requests for reprints should be addressed to John B. Cone, MD, Department of Surgery, Slot # 520, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72205. Presented at the 42nd Annual Meeting of the Southwestern Surgical Congress, La Quinta, California, April 22-25, 1990.
652
THE AMERICAN JOURNAL OFSURGERY
PATIENTS AND M E T H O D S The medical records of 147 patients transferred to the trauma service of the University Hospital of Arkansas between 1985 and 1988 were reviewed. Pediatric patients and burn patients were not included in this review as they were admitted to the Pediatric Surgical Service and the Burn Service, respectively. Patients transferred from local emergency rooms after stabilization only were excluded. Patients whose sole indication for transfer appeared to be financial were also excluded. Twenty-five patients were identified who were admitted to local hospitals for definitive care of their injuries and subsequently transferred to University Hospital for services not available locally. This group of patients forms the basis of this review. Medical records from University Hospital were reviewed in all cases. Records were requested from the transferring facility but in many cases were incomplete. Where possible, the information gaps were filled in by direct communication with the transferring physician. Pre-hospital records were rarely available. Records were reviewed to establish the indication for transfer, the time interval from injury to transfer, the method of transport, and the mechanism of injury. Insufficient information was available to calculate Trauma Scores, but Injury Severity Scores (ISSs) were computed. After arrival at University Hospital, the overall length of stay, length of stay in the intensive care unit, number of surgical procedures required, and blood utilization were recorded, as was patient outcome. After reviewing the data, an attempt was made to identify those services lacking in the community hospital that could be provided by transfer to a trauma center. No data were available on the overall incidence of rural trauma in Arkansas or the outcome of those patients who were not transferred. RESULTS Twenty-five patients (17 men, 8 women) were transferred to the Trauma Service of University Hospital after initial attempts at definitive care in community hospitals. Seventeen patients sustained blunt trauma and eight had penetrating trauma. The mean ISS was 23. This group did not differ significantly from our overall trauma population except by being older (40.2 years versus 32.4 years). Patients were transported an average of 113 miles (range: 31 to 210 miles), illustrating that direct transport from the scene to a trauma center was not feasible. The time interval from injury to transfer ranged from 4 hours to 65 days with a mean of 8.1 days. Early transfers were more often due to bleeding problems, whereas late transfers were usually due to sepsis or enterocutaneous fistulas. Thirteen of the patients were transported by helicopter
VOLUME 160 DECEMBER 1990
TRAUMA CARE IN A RURAL COMMUNITY
but due to the necessity of a round trip, air transport made little impact on patient care. Indications for transfer were grouped into categories, with several patients having more than one indication. The need for further complex surgical capability (14 patients) could be divided into a need for a cardiothoracic surgeon in 2 cases, a neurosurgeon in 5 cases, an orthopedist in 3 cases, and a general surgeon with additional experience in 7 cases (due to pancreatobiliary injuries in 3 cases, enterocutaneous fistulas in 3 cases, and liver resection in 2 cases). Nine patients were transferred because of coagulopathies that exceeded the local capabilities. Five patients required complex ventilatory support because of chest trauma, while five of the late transfers presented with sepsis and/or multiple organ system failure. Transfer patients such as these tended to have lengthy average hospital stays (43 days, range: 5 to 239 days) and intensive care unit stays (14 days, range: 2 to 54 days). They required a total of 60 surgical procedures and an average of 20 units of blood products. Eighty percent of these patients survived. Three of the five deaths were the result of sepsis and multiple organ system failure present prior to transfer that could not be reversed. The other two deaths were cardiac in origin and occurred in patients aged 76 years and 84 years. There were three injuries missed prior to transfer: one ruptured duodenum and two pancreatic ductal injuries. These patients survived. Three serious physician judgment errors were identified, comprising one inadequate resuscitation, one identified intra-abdominal abscess treated with antibiotics alone, and one shotgun wound that was not debrided and that led to myonecrosis and sepsis. The inadequately resuscitated patient died of multiple organ system failure. Other than the lack of specific surgical specialties in the rural communities, the major deficiencies were in the blood banks and critical care units. In most cases, there was no pathologist/hematologist to assist with the evaluation of coagulopathies, nor were sufficient quantities of blood products available. In many cases, critical care facilities and personnel were also lacking for services such as dialysis, parenteral nutrition, or complex mechanical ventilation. In general, patient care was limited by the local system rather than the qualifications of the physicians who were available. COMMENTS The focus of this review is a narrow one. It does not attempt to evaluate the overall quality of rural trauma care or to identify preventable trauma deaths. Such studies have been done [6] and have consistently found mortality higher in rural areas [2]. Several factors have been identified as playing a role in this excess mortality, including delays in finding the victim, long distances, and lack of skilled prehospital care. Efforts to provide the benefits of the urban trauma center to the rural trauma victim have focused on rapid stabilization and transport to the trauma center, usually
TABLE I Trauma Center Services Utilized to Supplement Rural Community Hospital Trauma Care Patients(n) Blood bank
6
Critical care capability Additional surgical specialists General surgery Cardiothoracic surgery Orthopedic surgery Neurosurgery
9 14 7 3 3 5
by helicopter [4]. These techniques save lives, but they do not solve the entire problem. Due to bad weather, long distances, and inadequate numbers of aircraft, many patients injured in rural areas will receive their definitive care in community hospitals. The trauma center's ability to support the community hospitals it serves does not end when the patient is admitted to the community hospital. The American College of Surgeons Committee on Trauma has recognized the role of the trauma center in providing tertiary care to those patients whose needs have exceeded the resources available locally [7]. However, this role of the trauma center has received relatively little attention. We have identified three major areas of support that the trauma center can provide (Table I). First is the availability of surgical specialists who, by virtue of additional training and/or high-volume experience, may offer services that small communities cannot support, such as neurosurgery or cardiothoracic surgery. Second are critical care services. These include not only adequate equipment and facilities, but sufficient highly trained nurses and in-house physicians. A critically injured patient may require more physician time than the community surgeon can spare. Third is blood bank support. Adequate quantities of blood and blood products, while vital, are not sufficient. A hematologist or hematopathologist with appropriate laboratory facilities is essential to evaluate the coagulopathies that often occur. The trauma center and the community hospital serving rural areas should not be competitors. They should work together to avoid duplication of resources and still provide high-quality trauma care. To ensure that all components of the system are working, a widespread data collection effort needs to be initiated. Only when the facts are known can rational and cost-effective efforts be made to improve trauma care. REFERENCES 1. Cales RH, Trunkey DD. Preventable trauma deaths. J A M A 1985; 254: 1059-63. 2. Baker SP, Whitfield RA, O'Neill B. Geographic variations in mortality from motor vehicle crashes. N Engl J Med 1987; 316: 1384-7. 3. Houtchens BA. Major trauma in the rural mountain west. J Am Coil Emerg Phys 1977; 6: 343-50. 4. Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: air versus ground. J Trauma
THE AMERICAN JOURNAL OF SURGERY
VOLUME 160 DECEMBER 1990
653
CONE
1989; 29: 780-94. 5. Rinker CF, Sabo RR. Operative management of rural trauma over a 10-yem" period. Am J Surg 1989; 158: 548-52. 6. Krob M J, Cram AE, Vargish T, et al. Rural trauma care: A study of trauma care in a rural emergency medical services region. Ann Emerg Med 1984; 13: 891-5. 7. American College of Surgeons--Committee on Trauma. Hospital and prehospital resources for optimal care of the injured patient. Bull Am Coil Surg 1983; 71: 4-12.
DISCUSSION Romano Deleore, Jr. (Kansas CitY, MO): Immediate transportation of the trauma patient from the injury site to a level I facility is simply not possible in many rural communities. Therefore, it remains critically important that the rural facility be able to provide initial resuscitation and surgical stabilization. Equally important, however, is the ability of the rural facility, and in particular of the community surgeon, to recognize when, despite their best efforts, the patient must be transferred to a specialized center. Unfortunately, this study excluded patients who were transferred immediately after stabilization. These patients would have provided a good control group. Do you have any information on the outcome of such patients? Did they do any better than patients who were cared for at the rural facility, and did patients with similar ISSs who were directly admitted to the trauma center have a better outcome?
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THE AMERICAN JOURNAL OF SURGERY
C a r e y P. P a g e (San Antonio, TX): Of 125 patients first reviewed, a large number of patients were eliminated who were transferred strictly for financial reasons. Of the 25 patients who form the basis of your report, was there any evidence of financial disincentive to transfer "funded" patients? That is, should any of the insured patients have been transferred to a level I trauma center earlier?
John B. Cone (closing): Dr. Delcore, we are currently looking at this same group of patients to include those transferred immediately after stabilization and to compare their outcomes with those who were cared for at the rural facilityl We are particularly interested in whether exposure of the transferring physician to Advanced Trauma Life Support training made any difference in the quality of the transfer. I do not have any data at this time on the outcome of those patients, nor do I have good data for our immediate admissions at this level of injury. We have not broken them down strictly by ISS, since we were unable to retrieve sufficient information on trauma scores. Dr. Page, we have not looked specifically at the financial incentives or disincentives. Many of the patients who were transferred for purely financial reasons were early in this series. That has dropped off significantly, but also, we have no good source of information for those patients who may have remained in local facilities for purely financial reasons.
VOLUME 160 DECEMBER 1990
T r a u m a patients in rural areas usually have no access to regional trauma systems or designated traun m centers. Efforts to provide quality trauma care in small hospitals m a y seriously overextend local capabilities. T h e urban trauma center retains an i m p o r t a n t role in trauma care even when the initial care must be p r o v i d e d at the local level. Twenty-five t r a u m a patients were transferred to University Hospital b e t w e e n 1 9 8 5 and 1 9 8 8 after definitive care was initiated in c o m m u n i t y hospitals. During the s a m e t i m e period, a total of 1 4 7 trauma patients were transferred to the trauma service. No i n f o r m a t i o n was available o n the total incidence of trauma. Medical records were reviewed to determine the reasons for transfer. Major reasons included the need for further complex surgery, better critical care support, and inadequate blood banks. T r a u m a centers serving rural areas provide a valuable resource well beyond the initial 2 4 hours.
omprehensive regional trauma systems reduce mortality after injury [I]. Despite the acceptance of this fact, the rural population of this country rarely has access to such care. Injury in a rural region has a disproportionately high mortality [2] even after entry into the medical care system [3]. Most discussions of this problem focus on local stabilization and rapid transfer to a trauma center [4]. For many reasons, this is often not feasible. Thus, the burden of trauma care falls on the community hospital and general surgeon. Rinker and Sabo [5] have recently reviewed trauma care from this perspective. This retrospective review was undertaken to clarify the role of the urban trauma center in providing tertiary support for rural community trauma care.
C
From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Requests for reprints should be addressed to John B. Cone, MD, Department of Surgery, Slot # 520, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72205. Presented at the 42nd Annual Meeting of the Southwestern Surgical Congress, La Quinta, California, April 22-25, 1990.
652
THE AMERICAN JOURNAL OFSURGERY
PATIENTS AND M E T H O D S The medical records of 147 patients transferred to the trauma service of the University Hospital of Arkansas between 1985 and 1988 were reviewed. Pediatric patients and burn patients were not included in this review as they were admitted to the Pediatric Surgical Service and the Burn Service, respectively. Patients transferred from local emergency rooms after stabilization only were excluded. Patients whose sole indication for transfer appeared to be financial were also excluded. Twenty-five patients were identified who were admitted to local hospitals for definitive care of their injuries and subsequently transferred to University Hospital for services not available locally. This group of patients forms the basis of this review. Medical records from University Hospital were reviewed in all cases. Records were requested from the transferring facility but in many cases were incomplete. Where possible, the information gaps were filled in by direct communication with the transferring physician. Pre-hospital records were rarely available. Records were reviewed to establish the indication for transfer, the time interval from injury to transfer, the method of transport, and the mechanism of injury. Insufficient information was available to calculate Trauma Scores, but Injury Severity Scores (ISSs) were computed. After arrival at University Hospital, the overall length of stay, length of stay in the intensive care unit, number of surgical procedures required, and blood utilization were recorded, as was patient outcome. After reviewing the data, an attempt was made to identify those services lacking in the community hospital that could be provided by transfer to a trauma center. No data were available on the overall incidence of rural trauma in Arkansas or the outcome of those patients who were not transferred. RESULTS Twenty-five patients (17 men, 8 women) were transferred to the Trauma Service of University Hospital after initial attempts at definitive care in community hospitals. Seventeen patients sustained blunt trauma and eight had penetrating trauma. The mean ISS was 23. This group did not differ significantly from our overall trauma population except by being older (40.2 years versus 32.4 years). Patients were transported an average of 113 miles (range: 31 to 210 miles), illustrating that direct transport from the scene to a trauma center was not feasible. The time interval from injury to transfer ranged from 4 hours to 65 days with a mean of 8.1 days. Early transfers were more often due to bleeding problems, whereas late transfers were usually due to sepsis or enterocutaneous fistulas. Thirteen of the patients were transported by helicopter
VOLUME 160 DECEMBER 1990
TRAUMA CARE IN A RURAL COMMUNITY
but due to the necessity of a round trip, air transport made little impact on patient care. Indications for transfer were grouped into categories, with several patients having more than one indication. The need for further complex surgical capability (14 patients) could be divided into a need for a cardiothoracic surgeon in 2 cases, a neurosurgeon in 5 cases, an orthopedist in 3 cases, and a general surgeon with additional experience in 7 cases (due to pancreatobiliary injuries in 3 cases, enterocutaneous fistulas in 3 cases, and liver resection in 2 cases). Nine patients were transferred because of coagulopathies that exceeded the local capabilities. Five patients required complex ventilatory support because of chest trauma, while five of the late transfers presented with sepsis and/or multiple organ system failure. Transfer patients such as these tended to have lengthy average hospital stays (43 days, range: 5 to 239 days) and intensive care unit stays (14 days, range: 2 to 54 days). They required a total of 60 surgical procedures and an average of 20 units of blood products. Eighty percent of these patients survived. Three of the five deaths were the result of sepsis and multiple organ system failure present prior to transfer that could not be reversed. The other two deaths were cardiac in origin and occurred in patients aged 76 years and 84 years. There were three injuries missed prior to transfer: one ruptured duodenum and two pancreatic ductal injuries. These patients survived. Three serious physician judgment errors were identified, comprising one inadequate resuscitation, one identified intra-abdominal abscess treated with antibiotics alone, and one shotgun wound that was not debrided and that led to myonecrosis and sepsis. The inadequately resuscitated patient died of multiple organ system failure. Other than the lack of specific surgical specialties in the rural communities, the major deficiencies were in the blood banks and critical care units. In most cases, there was no pathologist/hematologist to assist with the evaluation of coagulopathies, nor were sufficient quantities of blood products available. In many cases, critical care facilities and personnel were also lacking for services such as dialysis, parenteral nutrition, or complex mechanical ventilation. In general, patient care was limited by the local system rather than the qualifications of the physicians who were available. COMMENTS The focus of this review is a narrow one. It does not attempt to evaluate the overall quality of rural trauma care or to identify preventable trauma deaths. Such studies have been done [6] and have consistently found mortality higher in rural areas [2]. Several factors have been identified as playing a role in this excess mortality, including delays in finding the victim, long distances, and lack of skilled prehospital care. Efforts to provide the benefits of the urban trauma center to the rural trauma victim have focused on rapid stabilization and transport to the trauma center, usually
TABLE I Trauma Center Services Utilized to Supplement Rural Community Hospital Trauma Care Patients(n) Blood bank
6
Critical care capability Additional surgical specialists General surgery Cardiothoracic surgery Orthopedic surgery Neurosurgery
9 14 7 3 3 5
by helicopter [4]. These techniques save lives, but they do not solve the entire problem. Due to bad weather, long distances, and inadequate numbers of aircraft, many patients injured in rural areas will receive their definitive care in community hospitals. The trauma center's ability to support the community hospitals it serves does not end when the patient is admitted to the community hospital. The American College of Surgeons Committee on Trauma has recognized the role of the trauma center in providing tertiary care to those patients whose needs have exceeded the resources available locally [7]. However, this role of the trauma center has received relatively little attention. We have identified three major areas of support that the trauma center can provide (Table I). First is the availability of surgical specialists who, by virtue of additional training and/or high-volume experience, may offer services that small communities cannot support, such as neurosurgery or cardiothoracic surgery. Second are critical care services. These include not only adequate equipment and facilities, but sufficient highly trained nurses and in-house physicians. A critically injured patient may require more physician time than the community surgeon can spare. Third is blood bank support. Adequate quantities of blood and blood products, while vital, are not sufficient. A hematologist or hematopathologist with appropriate laboratory facilities is essential to evaluate the coagulopathies that often occur. The trauma center and the community hospital serving rural areas should not be competitors. They should work together to avoid duplication of resources and still provide high-quality trauma care. To ensure that all components of the system are working, a widespread data collection effort needs to be initiated. Only when the facts are known can rational and cost-effective efforts be made to improve trauma care. REFERENCES 1. Cales RH, Trunkey DD. Preventable trauma deaths. J A M A 1985; 254: 1059-63. 2. Baker SP, Whitfield RA, O'Neill B. Geographic variations in mortality from motor vehicle crashes. N Engl J Med 1987; 316: 1384-7. 3. Houtchens BA. Major trauma in the rural mountain west. J Am Coil Emerg Phys 1977; 6: 343-50. 4. Boyd CR, Corse KM, Campbell RC. Emergency interhospital transport of the major trauma patient: air versus ground. J Trauma
THE AMERICAN JOURNAL OF SURGERY
VOLUME 160 DECEMBER 1990
653
CONE
1989; 29: 780-94. 5. Rinker CF, Sabo RR. Operative management of rural trauma over a 10-yem" period. Am J Surg 1989; 158: 548-52. 6. Krob M J, Cram AE, Vargish T, et al. Rural trauma care: A study of trauma care in a rural emergency medical services region. Ann Emerg Med 1984; 13: 891-5. 7. American College of Surgeons--Committee on Trauma. Hospital and prehospital resources for optimal care of the injured patient. Bull Am Coil Surg 1983; 71: 4-12.
DISCUSSION Romano Deleore, Jr. (Kansas CitY, MO): Immediate transportation of the trauma patient from the injury site to a level I facility is simply not possible in many rural communities. Therefore, it remains critically important that the rural facility be able to provide initial resuscitation and surgical stabilization. Equally important, however, is the ability of the rural facility, and in particular of the community surgeon, to recognize when, despite their best efforts, the patient must be transferred to a specialized center. Unfortunately, this study excluded patients who were transferred immediately after stabilization. These patients would have provided a good control group. Do you have any information on the outcome of such patients? Did they do any better than patients who were cared for at the rural facility, and did patients with similar ISSs who were directly admitted to the trauma center have a better outcome?
654
THE AMERICAN JOURNAL OF SURGERY
C a r e y P. P a g e (San Antonio, TX): Of 125 patients first reviewed, a large number of patients were eliminated who were transferred strictly for financial reasons. Of the 25 patients who form the basis of your report, was there any evidence of financial disincentive to transfer "funded" patients? That is, should any of the insured patients have been transferred to a level I trauma center earlier?
John B. Cone (closing): Dr. Delcore, we are currently looking at this same group of patients to include those transferred immediately after stabilization and to compare their outcomes with those who were cared for at the rural facilityl We are particularly interested in whether exposure of the transferring physician to Advanced Trauma Life Support training made any difference in the quality of the transfer. I do not have any data at this time on the outcome of those patients, nor do I have good data for our immediate admissions at this level of injury. We have not broken them down strictly by ISS, since we were unable to retrieve sufficient information on trauma scores. Dr. Page, we have not looked specifically at the financial incentives or disincentives. Many of the patients who were transferred for purely financial reasons were early in this series. That has dropped off significantly, but also, we have no good source of information for those patients who may have remained in local facilities for purely financial reasons.
VOLUME 160 DECEMBER 1990