Rural Trauma Center Research Articles

Motorcycle Collisions Involving White-Tailed Deer in Central and Northern Wisconsin: A Rural Trauma Center Experience

Risk of deer motorcycle collisions (DMC) continues to increase in Midwestern and East Coast States and is a growing regional public health issue. We conducted a retrospective chart review of all motorcycle collisions involving animals over a 9-year period from October 1993 to October 2002. Data collected included Injury Severity Score (ISS), injury type, outcome, use of helmets/alcohol, time of year/day. Fifty-five DMC were identified, 49 drivers, and 6 passengers. ISS for helmeted patients was 6.02+/-4.6 and 17.6+/-14.9 for non-helmeted patients. There were 7 human fatalities (all without helmets). Of the 55 patients, 16% of those injured were intoxicated, without helmets, and had average ISS higher than those non-intoxicated. Head, chest and orthopedic extremity trauma accounted for >70% of injuries seen within the entire population. Incidence peaked in June/July, and 55% of the collisions occurred between the hours of 1800 and 2200. DMC are a significant public health issue in mid-western states. Education about helmet and alcohol use and safety on rural roads may be the best prevention. Continued research focusing on prevention is necessary.

Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients.

To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.

Mortality Benefit of Transfer to Level I versus Level II Trauma Centers for Head‐Injured Patients

Objective. To determine whether head‐injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers.Data Source/Study Setting. Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994.Study Design. A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30‐day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument.Principal Findings. Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers.Conclusions. Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.

The Evolving Management of Blunt Hepatic Trauma in a Rural Setting

Over the past decade, a nonoperative approach toward the management of blunt hepatic trauma has become prevalent at most major urban trauma centers. To determine the applicability of the nonoperative approach in a rural setting, a 10-year retrospective review was conducted at a level I rural university-based trauma center. The Census Bureau defines ruralized areas to provide a better separation of urban and rural territory and population. A ruralized area is composed of one or more places and the adjacent surrounding territory that together have a maximum of 50,000 persons. West Virginia University is classified as a rural academic medical center and is situated in Morgantown, whose permanent population does not exceed 35,000. All patients with documented blunt hepatic trauma between July 1990 and June 2000 were identified and reviewed. To evaluate evolving trends, the patients were divided into two groups: group A (July 1, 1990-June 30, 1995) and group B (July 1, 1995-June 30, 2000). There were 236 patients with documented blunt hepatic trauma identified between July 1, 1990, and June 30, 2000). Overall, 70 per cent of patients were managed conservatively. When comparing the two groups, statistical significance was obtained in mean hospital length of stay (LOS) [19.8 days A vs. 9.1 days B (P < 0.0001)]; mean intensive care unit (ICU) days [15.2 days A vs. 5.3 days B (P < 0.0001)], blood transfusion [10 units A vs. 4.2 units B (P < 0.0016)], number of patients requiring surgery [52 (46%) A vs. 37 (30%) B (P < 0.022)]. There was only one death associated with nonoperative management. We have shown a definite trend toward nonoperative management of blunt hepatic trauma in a rural setting over the past decade. More than 70 per cent of our liver injury patients over the past 5 years have been managed nonoperatively, with statistically significant reductions in hospital LOS, ICU LOS, and transfusion requirements. We have found a definite trend over the past decade toward nonoperative management of blunt hepatic trauma in a rural setting. The rural setting with a delay in transport time to level I trauma center also did not significantly affect the outcome of the patients with nonoperative management of liver injuries. Approximately 78 per cent of our liver injury patients over the past 5 years have been managed nonoperatively and are associated with statistically significant reductions in hospital and ICU LOS and transfusion requirements.

Popliteal Artery Trauma in a Rural Level I Trauma Center

Popliteal vascular trauma has historically been an urban phenomenon. We hypothesized that rural popliteal artery injury would result more often from blunt mechanisms of injury (MOI), have a longer time to operation, and result in a higher amputation rate. We retrospectively reviewed all cases of popliteal artery injury from December 1994 to May 2001 at our rural trauma center. Age, gender, Injury Severity Score (ISS), MOI, scene transport versus transfer from a referring hospital, time to operation, and operative times were studied. Significance was determined by Student's t test with a P value < or = 0.05. Thirty-two popliteal artery injuries were found. Blunt trauma accounted for 50 per cent of the injuries. Eighty-eight per cent of the patients were transferred from a referring hospital. Patients transported directly from the scene had a higher ISS. Longer operative times translated into an increased need for fasciotomy. The amputation rate was 19 per cent. This is the first attempt to delineate the specific nature of rural popliteal artery trauma. The amputation rate was not different between the two different MOI and was independent of the time to operation. Of those patients receiving an amputation 83 per cent were transferred from another hospital and despite a statistically lower ISS still required an amputation.

When the Bough Breaks: A 10-Year Review of Logging Injuries Treated at a Rural Trauma Center in Pennsylvania

The purpose of this study was to describe logging-related injuries at a Pennsylvania trauma center and evaluate the impact of helmets and profession. Charts of patients from 1990 through 1999 admitted after logging accidents were retrospectively reviewed. Most injuries were to the head (71 in 28 patients). Injury Severity Score was greater for helmeted loggers (21.0 vs 11.8; P = 0.02) but did not differ by profession. Mean hospital stay was not significantly different for helmeted loggers (9.6 vs 5.4 days, P = 0.499). Mean length of stay was 8.2 days and 3.5 days for professionals and nonprofessionals, respectively (P = 0.01). Professional loggers tended to remain hospitalized longer. Helmet use does not appear to affect injury severity; however, this could be a result of the catastrophic nature of many logging accidents. Most loggers in this study were not wearing helmets, which suggests that improved educational efforts are needed to improve safety in this dangerous occupation.

Survival of seriously injured patients first treated in rural hospitals.

Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers. Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge. Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital. In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

Background. Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care. Methods. Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care. Results. Mean CPS for 506 PRE period patients (0.44 ± 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 ± 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 ± 0.19) was significantly higher than the mean CPS of decedents (0.57 ± 0.25). Conclusions. Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care. (Surgery 2001;130:273-9.)

Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting.

To determine the characteristics and outcome of transferred trauma patients in a rural setting. We conducted a case-control study of all trauma admissions to a rural Level I trauma center to examine a 3.5-year (1993-1996) comparison of trauma patients admitted directly with those transferred (RTTP) after being initially stabilized at an outlying hospital. We used prehospital times, Injury Severity Score (ISS), LD50ISS (the ISS at which 50% of patients died), Revised Trauma Score, probability of survival, Acute Physiology and Chronic Health Evaluation II, and observed survival as main outcome measures. RTTPs (39.4%) spent an average of 182+/-139 minutes at the outlying hospital and 72+/-42 minutes in transport to the trauma center. Proportionately more head/neck and patients with multiple injuries composed the RTTP group. The RTTP were more severely injured (ISS 11.1+/-8.5; Acute Physiology and Chronic Health Evaluation II 16.2+/-5.8; Revised Trauma Score 7.44+/-1.1) than the trauma patients admitted directly (ISS 7.9+/-5.3; Acute Physiology and Chronic Health Evaluation II 13.1+/-6.3; Revised Trauma Score 7.8+/-0.4; p < 0.05). However, both groups had the same LD50ISS (ISS = 35). When logistic regression was applied with death as the dependent variable, both ISS and age contributed significantly (p = 0.0001) but transfer status did not (p = 0.473). Rural trauma centers admit a high percentage of RTTP. These RTTP have a higher injury severity and acuity than their trauma patients admitted directly counterparts. Trauma care in rural areas that involves initial stabilization at outlying hospitals does not adversely affect mortality.

Cofactors of alcohol-related trauma at a rural trauma center

To analyze the cofactors of alcohol-related trauma at a rural, Level II trauma center, 127 admitted trauma patients were interviewed about psychological problems, social factors, and medical histories. Patients were divided into two groups, blood alcohol content (BAC) positive and BAC negative, for analysis. Seventy-one patients (56%) were BAC negative; 56 (44%) were BAC positive. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) ( P = .01). Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) ( P = .0001). Ten of the 12 patients (83%) who were recently unemployed were BAC positive, compared with 46 of the 115 patients (40%) who were not recently unemployed ( P = .004). Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens ( P = .0005). These results show that there are important cofactors of alcohol-related trauma in rural areas.

Difficulties in substance abuse rehabilitation in a rural trauma center

Difficulties in substance abuse rehabilitation in a rural trauma center

Financial outcome of treating trauma in a rural environment.

The financial plight of the urban trauma center is well documented. However, the financial status of the rural trauma center is largely unknown. We hypothesized that our rural trauma center with a high number of blunt trauma patients, a wide spectrum of injury severity, and a large percentage of insured patients would prove to be financially advantageous to the institution. From January 1994 to June 1995, 1,119 consecutive trauma admissions had a complete financial profile compiled including actual costs, reimbursements, and reimbursement ratio (RR = reimbursement/actual costs). Our injury severity profile was very skewed with a preponderance of less severely injured patients (mean Injury Severity Score = 9.6 +/- 7.8). The payor profile of these patients included 49.2% fee-for-service (RR = 1.43), 25.4% diagnosis-related group-based (RR = 0.92), 8.77% per diem (RR = 0.51), and 1.25% capitated (RR = 0.47). Overall, the RR for the trauma unit was 1.11, representing a net profit overall. Cost closely tracked both hospital and intensive-care unit length of stay (R2 = 0.925). Likewise, reimbursement also was reflected in both hospital and intensive-care unit length of stay (R2 = 0.735). We conclude that our rural trauma center, with a favorable payor mix and low injury severity, is financially profitable.

Missed injuries in a rural area trauma center

Missed injuries can lead to delays. In the rural environment, where patients are frequently seen in multiple hospitals prior to reaching the trauma center, different problems arise. Level-1 trauma center admissions from January 1993 through June 1995 were reviewed. Missed injuries were those not identified within 24 hours of injury. Data extracted included demographics, mechanism, severity and outcome. Comparisons were made between missed injury patients and typical trauma patients. Of 3,996 patients, 70 missed injuries were identified in 56 patients. Compared with typical trauma patients, missed injury patients suffered more blunt trauma, were more severely injured, had longer intensive care unit and hospital stays, and a lower mortality rate. Transferred patients accounted for 60% of missed injuries. Transferred patients with blunt injury have the highest risk for missed injury. Delayed transports and prior examination may contribute to complacency. All trauma patients must be repeatedly evaluated thoroughly, and all diagnostic studies reviewed for adequacy.

Delayed diagnosis in a rural trauma center

The rapid and accurate diagnosis of all injuries is critical in trauma surgery. Injuries not diagnosed after the secondary survey are not without serious consequences. Therefore, in an effort to decrease this problem a policy was initiated to perform an ongoing serial exam during the entire course of each patient's involvement with the trauma team at Saint Francis Medical Center. Prospective identification and evaluation of patients admitted to a single trauma service with delayed diagnosis was done from July 1, 1993, to October 31, 1995. Sixty-eight delayed diagnoses were identified in 56 patients, for an incidence of 3% of the total 1876 patients evaluated. The vast majority were nonspinal orthopedic injuries (63%). Of seven missed spinal fractures, only one resulted in permanent paralysis. The remaining injuries missed were 11 injuries located in the head and neck area, 3 arterial injuries, 3 pneumothoraces, and 2 small bowel injuries. Thirty-four percent of the patients required surgical intervention for these injuries and one patient died because of the delay. There was a high association of delayed diagnosis in victims with altered mental status, victims intubated in the field, and individuals requiring immediate operation. Twenty percent of our total missed injuries could have been avoided if a thorough evaluation of initial films had been done. Delayed diagnosis remains a problem in all trauma centers. This study demonstrates that to keep this problem at a reasonable rate, we must: (1) carefully review initial x rays; (2) repeat any study that is not clear; and (3) continue serial examinations of each patient for the entire clinical course. Objective and thoughtful discussion of missed injuries on a routine basis will also keep this problem minimal.

Moose-motor vehicle collisions. An increasing hazard in northern New England.

To analyze the epidemiology and epizootiology of moose-motor vehicle collisions (MMVC) and outcomes in severely injured patients to identify variables that might be modified to reduce the impact of this mutually deleterious interspecies interaction. Wildlife and Traffic Safety databases permitted retrospective, population-based assessment of MMVC epidemiology. A case series compiled from hospital trauma registries characterized morbidity and mortality from MMVC. New Hampshire and Maine area. All victims of MMVC (1980 through 1991) were included in population-based analyses. Twenty-three patients hospitalized at three rural trauma centers (January 1990 through June 1994) were included in the case series. Location, time of day and seasonal occurrence of MMVC were determined. Injury patterns and Injury Severity Scores were analyzed in 23 representative patients. Maine's 1991 traffic and medical data were linked, and factors predictive of injury from MMVC were identified using multivariate logistics. Most MMVC occur from April through October after dark. Of 23 subjects, 70% sustained head and/or face injuries and 26%, cervical spine injuries. Mortality was 9%. Mean Injury Severity Score was 15.7 (SD=9.0). Safety belt use, rear seat location, and light truck occupancy were associated with reduced injury (p<.05). Moose-motor vehicle collisions are increasing in rural regions. Prevention programs should emphasize defensive driving and seat belt use, especially during high-risk periods. Injury patterns in MMVC suggest a need for automobile design modifications that better protect the passenger compartment form direct impact.

Injury and violence in Los Angeles. Impact on access to health care and surgical education.

The Los Angeles County (California) Trauma Hospital System was designed to ensure that all patients requiring specialized trauma care would be transported directly to a trauma center using established trauma triage criteria. The designation and implementation of all level 1, 2, and 3 (rural) trauma centers were completed between October 1983 and July 1985. However, by February 1, 1985, one level 2 trauma center withdrew, and nine other level 2 and 3 trauma centers followed suit over the next few months and years. The reasons for closure of these 10 trauma centers were almost exclusively related to economic factors. The major impact of trauma center closure on surgical educational programs at the Drew University of Medicine and Science and the Martin Luther King, Jr/Charles R. Drew Medical Center have been additive and cumulative. The high volume of patients with trauma has been cited, sometimes correctly and sometimes incorrectly, as the primary reason for a lack of access to health care for patients without trauma. We have developed a blueprint for survival that, when fully implemented, will improve access to health care for all residents in our catchment area and optimize surgical education. While the Los Angeles County Trauma Hospital System has had many difficulties during the last 9 years, the population it serves is greater than that in 42 states in the United States. The experiences gained in Los Angeles County may be beneficial to statewide systems in the United States and in countries of comparable size.

Differences in trauma care among pediatric and nonpediatric trauma centers

To characterize pediatric trauma care, state trauma registry data from all designated trauma centers in Pennsylvania were divided into three categories, that from: (1) pediatric centers, (2) urban nonpediatric centers, (3) and rural nonpediatric centers. From October 1, 1986 through September 30, 1989 (3 years), 4,615 patients less than 15 years old were admitted to 28 trauma centers in Pennsylvania. Nonpediatric centers cared for the majority of children (2,734, 59.2%), but the average number of children treated per nonpediatric institution (105.1 per year) was far fewer than the average treated in the pediatric centers (940.5). Pediatric trauma centers in the state treated a younger population (6.4 ± 4.2 years, mean ± SD) compared with urban and rural nonpediatric centers (8.4 ± 4.2 and 8.1 ± 4.3 years, respectively; P < .05). Pediatric centers received proportionately more children by transfer (56.2%), victims of falls (34.6%), pedestrian injuries (16.8%), and head and neck injuries (41.8%, all P < .05). Nonpediatric centers received children directly from the scene of injury more frequently than transferred from other hospitals. The male:female sex ratio in urban nonpediatric centers was significantly higher (70.1%, P < .05) than in the other two groups. Rural nonpediatric centers cared for a higher proportion of motor vehicle passengers (28.5%) and patients classified as “other” in the state registry, a category to which bicycle injuries are assigned (28.2%, P < .05). Mortality was highest in rural nonpediatric centers (6.2%). The death rate in pediatric centers and urban nonpediatric centers were similar (4.1%) and significantly lower ( P < .05). Mortality from pedestrian injuries was higher in rural centers (15.1%); other injury mechanisms exhibited no regional differences in mortality. Using TRISS, z for rural centers (1.123) failed to reach statistical significance, whereas z for pediatric and urban nonpediatric centers reached significance (3.896 and 3.335, respectively). Using the probability of survival (P(s)) generated by TRISS analysis, no significant differences in survival were noted among the three groups of trauma centers when P(s) was stratified, although survival was slightly higher in pediatric centers for P(s) ≥.3 and <.6. Important regional differences in pediatric trauma care exist, specifically major differences in patient age, injury, and referral source. Rural trauma centers have a higher pediatric mortality than urban centers, a possible result of differences in access to prehospital care.

Improved trauma care in a rural hospital after establishing a level II trauma center

A study of motor vehicle accident deaths occurring in Napa County, California, from 1979 through 1983 showed that there was a preventable death rate of 42% for deaths that were not related to central nervous system injuries. After developing a Level II trauma center at our hospital, the preventable death rate decreased to 14%. This was statistically significant (total chi-square, 0.01 less than p less than 0.025). There was a significant increase in the average Injury Severity Score (34 versus 45, p less than 0.005) as well as significant improvements in the surgeon's response time (32 minutes versus 11 minutes, p less than 0.005) and in the time from hospital arrival to the start of surgery (3.6 hours versus 1.9 hours, 0.01 less than p less than 0.025). We conclude that these changes are indicative of improved trauma care and reflect favorably upon the effectiveness of a rural trauma center that meets Level II trauma center guidelines established by the American College of Surgeons Committee on Trauma.

Comparison of complication and mortality rate between direct trauma admissions and transfer trauma admissions to a rural trauma center

Comparison of complication and mortality rate between direct trauma admissions and transfer trauma admissions to a rural trauma center

Acute gastric dilatation after trauma.

During a 2-year period, 248 consecutive patients were admitted with multiple trauma. Acute gastric dilatation was documented in 67 (27%) patients by review of all admission roentgenograms. There were 51 (76%) males and 16 females. Ages ranged from 2 to 80 years (mean, 29.2 years). The incidence of acute gastric dilatation in children was 44% vs. 25% for adults (p less than 0.05). The mechanism of injury was motor vehicle accident in 45 (67%), agricultural accident in 8 (12%), fall in four (6%), bicycle accident in four (6%), and miscellaneous in six (9%). There were 38 orthopedic, 35 craniocerebral, 34 abdominal, 31 thoracic, 27 maxillofacial, and 14 spinal injuries. Injury Severity Scores ranged from 4 to 66 (mean, 23.5). Thirteen (19%) patients presented in shock and there were four (6%) hospital deaths. No death was attributable to gastric dilatation. Nasogastric tubes were placed in 41 (61%) patients and 26 were managed without tube placement. Complications associated with acute gastric dilatation included pulmonary aspiration in three (4%) patients, gastric hemorrhage in three (4%), gastrointestinal perforation in one (1%), and prolonged ileus in 12 (18%). In addition, gastric dilatation rendered abdominal examination difficult and delayed peritoneal lavage. Acute gastric dilatation after trauma is frequent in our rural trauma center. Early placement of a nasogastric tube in the absence of a clear contraindication is strongly supported in the management of multiply injured patients.