Literature / Litterature scientifique
Can J Rural Med 1997; 2 (2):90
© 1997 Society of Rural Physicians of Canada
The management of trauma in rural hospitals is an issue that keeps recurring in the literature. Issues of assessment, treatment, transport and outcome continue to be debated, with evidence from both sides either supporting or questioning the efficacy of trauma management systems.
One frequent element of trauma care planning is the Advanced Trauma Life Support Course (ATLS). Its historical roots can be traced to rural primary care. The course was initiated in 1978 in an attempt to provide a structured approach to trauma care in rural areas. Its popularity has grown such that it is now the course most often recommended for ER physicians working in urban as well as rural areas. In 1993 the experience with the course was reviewed in Manitoba.
The Advanced Trauma Life Support Program in Manitoba: a 5-year review.
Ali J, Howard M.
Can J Surg 1993;36(2):181-3.
This review determined that the course enjoyed a high level of popularity among participants. Subjectively, 93% of registrants reported that the course increased their confidence, and some department of surgery heads (both urban and rural) had the impression that the timeliness and appropriateness of consultations improved and that mortality and morbidity were decreased when care was provided by ATLS-trained physicians. These impressions were not, however, documented objectively. The review also showed that the great majority (207/302) of registrants for this course were from urban areas.
ATLS does not, by itself, a trauma system make. Although the specific training of providers is important, the following study from the Department of Emergency Medicine, University of Kentucky, documents the importance of the facilities at the front line of rural trauma care.
Factors associated with the higher traumatic death rate among rural children.
Svensen JE, Spurlock C, Nypaver M.
Ann Emerg Med 1996;27(5):625-32.
This study examined all traumatic pediatric deaths in Kentucky between 1988 and 1992. Results showed that death rates were highest in rural Kentucky, but were lower where 24-hour emergency services and advanced pre-hospital support were available. The authors stated: "Increased access to quality care and training of pre-hospital providers in advanced life support should be priorities in the planning of trauma systems for this state." This study supports the position that rural hospitals are a vital link in the chain of survival for trauma patients.
The preoccupation with trauma care systems is evident elsewhere in the literature. The following article, from the Division of Neurological Surgery, University of Vermont, Burlington, examined neurologic trauma in rural Vermont.
The effect of secondary insults on mortality and long-term disability after severe head injury in a rural region without a trauma system.
Wald SL, Shackford SR, Fenwick J.
J Trauma 1993;34(3):377-81; discussion: 381-2.
This study of trauma patients hypothesized that outcomes of severe head injury would be worse if these patients presented to rural hospitals that did not have an organized system for trauma care. It was felt that in these cases patients would have an increased incidence of secondary insults such as hypoxia or hypotension, and that this would lead to poorer outcomes.
The study succeeded in confirming the importance of secondary insults and did in fact identify a group of patients at increased risk of a poor outcome. But the authors also found that "there was no difference in outcome of patients similarly grouped according to the presence or absence of secondary insults between Vermont's rural cohort and the urban cohort." This suggested to the authors that significant brain injury often occurs too early in the course of trauma for the outcome to be affected significantly by even the most efficient trauma system.
In an era of increased emphasis on quality assurance and outcomes measurement, the problems associated with interhospital transfers can be a source of subtle pressures on the system.
Impact of interhospital transfers on outcomes in an academic medical center. Implications for profiling hospital quality.
Gordon HS, Rosenthal GE.
Med Care 1996;34(4):295-309.
This study from a Midwestern academic centre -- the Division of General Internal Medicine, Department of Medicine, University Hospitals of Cleveland, Ohio -- demonstrated that, in general, transferred patients had higher severity-of-illness scores than those admitted directly and that this difference was reflected in the hospital's outcome profile.
The authors estimated that "independent of quality of care, severity adjusted mortality and length of stay would appear to be 17% and 8% higher, respectively, for hospitals in which 20% of patients were interhospital transfers than for hospitals in which 2% of patients were transfers."
This study highlights not only the fact that transferred patients are sicker than the norm, but also that unless this fact is taken into account when producing outcome profiles, it may create "disincentives for hospitals to accept transfers from other acute care facilities."
The consideration of the global care of critically ill patients, including trauma victims, has led to the development of practice guidelines for their safe transfer, as reported in the following paper.
Guidelines for the transfer of critically ill patients.
Guidelines Committee, American College of Critical Care Medicine, Society of Critical Care Medicine and the Transfer Guidelines Task Force.
Am J Crit Care 1993;2(3):189-95.
The authors present their guidelines as being evidence-based. They address critical elements of the transfer process: coordinating pre-transport, proper communication, transport equipment, accompanying personnel, monitoring during transport and documentation. However, they stress that there is a relative lack of "well designed clinical outcome studies" in the literature and that, therefore, guideline implementation such as they suggest should be subject to the process of "continuous quality improvement."
