Stabilization of Rural Multiple-Trauma Patients at Level III Emergency Departments Before Transfer to a Level I Regional Trauma Center,☆☆,

Presented at the American College of Emergency Physicians Research Forum in San Diego, California, March 1994.
https://doi.org/10.1016/S0196-0644(95)70320-9Get rights and content

Abstract

Study objective: To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data.

Design: Retrospective review of trauma transfers and deaths during a 4-year period. Setting: Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center. Participants: Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of ≤11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED. Results: There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, –.7l0. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps=.32, Ps=.49) and 1 unexpected death (Ps=.52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps=.66, Ps=.55). The predicted number of deaths was 5.4 whereas the actual number was 7. Conclusion: Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similiar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs. [Veenema KR, Rodewald LE: Stabilization of rural multiple-trauma patients at Level III emergency departments before transfer to a Level I regional trauma center. Ann Emerg Med February 1995;25:175-181.]

Section snippets

INTRODUCTION

Several studies have demonstrated an increased risk of dying from trauma when a patient is injured in a rural area with a low population density and is treated at a small rural hospital.1, 2, 3 The failure to recognize injury severity, the failure to institute appropriate standard resuscitative treatment procedures, and the lack of timely surgical involvement have been implicated as factors contributing to death.4, 5, 6 Level I trauma centers must receive trauma patients from rural areas in a

MATERIALS AND METHODS

Wayne County, in upstate New York, is a large, predominantly rural county east of Rochester with a population of 85,000 and covering 607 square miles. Two hospitals serve the county: Newark-Wayne Community Hospital (80 acute-care beds) and Myers Community Hospital (50 acute-care beds). Each hospital's ED approximates Level III criteria as established by the American College of Surgeons Committee on Trauma guidelines. This was determined after author review of the services available at each

RESULTS

Fifty patients met the study entry criteria; 41 (82%) were male. The mean age was 34 years (range, 9 months to 97 years). Eleven patients (22%) were younger than 18 years. Forty-five patients (90%) were victims of blunt trauma. Of these, the cause of trauma was motor vehicle accident for 36 (72%), a fall for 7 (14%), and other blunt injury for 2 (4%). Motor vehicle accident victims included five (10%) bicyclists struck by cars, six (12%) pedestrians struck by cars, and two (4%) involved in

DISCUSSION

In the 1980s, regionalized trauma care predominantly took place in areas with a high population density and short transportation distances and benefited from adequate funding. The problems inherent to rural areas with low population density have been documented.1, 2, 3, 4, 5, 6

Baker and O'Neil1 demonstrated an inverse correlation between population density and mortality from motor vehicle crashes. The higher death rates in rural areas with a low population density were attributed to higher

CONCLUSION

Triage and stabilization of severely injured rural trauma victims at rural Level III EDs before Level I transfer can provide outcomes comparable to national standards. Unexpected death before transfer remains a problem in rural Level III EDs. The establishment and staffing of rural Level III EDs by emergency physicians may have a profound impact in the care of the rural trauma victim, because emergency physicians have expertise in trauma care and resuscitation.

Acknowledgements

The authors thank Jean Welch, RN (Trauma Coordinator, Strong Memorial Hospital), and Sam Bean, RN (Nurse Manager, ED at Myers Community Hospital), for their help in data collection.

References (18)

There are more references available in the full text version of this article.

Cited by (44)

  • Outcomes of rural trauma patients who undergo damage control laparotomy

    2019, American Journal of Surgery
    Citation Excerpt :

    While not specifically addressing DCL, Veenema and Rodewald discussed the importance of stabilizing rural patients at level III emergency departments before transfer to level 1 trauma center.12 Using TRISS methodology, they were able to show that with stabilization at a level III facility, the number of actual deaths was less than the predicted number of deaths.12 DCL should be included as a tool for stabilization.

  • The impact of transfer on pediatric trauma outcomes

    2016, Journal of Pediatric Surgery
  • Trauma

    2008, Emergency Medicine Clinics of North America
  • Improving outcomes in a regional trauma system: impact of a level III trauma center

    2006, American Journal of Surgery
    Citation Excerpt :

    This supports the hypothesis that regional trauma center care after initial evaluation and resuscitation elsewhere can be effective even when timing of transfer is suboptimal. Veenema and Rodewald [3] reported that triage and stabilization of severely injured rural trauma victims at a level III emergency department before transfer to a level I trauma center resulted in outcomes similar to MTOS data. Rogers et al [4] similarly demonstrated that trauma care in rural areas involving initial stabilization at outlying hospitals did not adversely affect mortality.

  • Strategic Decision-Making in Trauma Systems

    2024, Lecture Notes in Computer Science (including subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics)
View all citing articles on Scopus

From the Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.

☆☆

Address for reprints: Kenneth R Veenema, MD, FACEP, Department of Emergency Medicine, 601 Elmwood Avenue, Box 655, Rochester, New York 14642, 716-275-4503

Reprint no. 47/1/61848

View full text