Trauma care at rural level III trauma centers in a state trauma system

The Isolated Surgeon: A Scoping Review

BACKGROUND

Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care.

METHODS

We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role.

RESULTS

From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings.

CONCLUSIONS

This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care

BACKGROUND

There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients.

METHODS

This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center.

RESULTS

We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage.

CONCLUSIONS

Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.

Predicting Outcomes of Penetrating Cardiovascular Injuries at a Rural Center by Different Scoring Systems

OBJECTIVE

To compare the anatomical and physiological scoring systems and the outcomes of surgical management of penetrating cardiovascular trauma at a rural center.

METHODS

Seventy-seven patients underwent emergency surgery at our center between January/2012 and October/2018 due to penetrating cardiovascular trauma. Injury Severity Score (ISS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), and Trauma and Injury Severity Score (TRISS) were calculated. The validation of these risk scores to predict mortality was assessed by the area under the receiver operating characteristic curve analysis.

RESULTS

All trauma scores were correlated with mortality. As ISS, NISS, and TRISS values increased and RTS values decreased, the mortality rate increased. The area under the curve (AUC) in the receiver operating characteristic curve analysis was 0.943 for TRISS, 0.915 for RTS, 0.890 for ISS, and 0.896 for NISS (P<0.001 for each). Logistic regression analysis revealed that scores were correlated with mortality (P<0.001 for each). By investigating cardiac injuries alone, only TRISS and RTS results correlated with mortality for cardiac injuries (Mann-Whitney U test, P=0.003 and P=0.01, respectively). The AUC was only statistically significant for TRISS and RTS (AUC=0.929, P<0.05 for both). For vascular injuries, all the scores were significantly correlated with in-hospital mortality (Mann-Whitney U test, P<0.001 for each). TRISS had the highest AUC (AUC=0.946, P<0.001).

CONCLUSION

TRISS has the highest predictivity for in-hospital mortality in patients with penetrating cardiovascular trauma.

Use of Plasma-Based Trauma Transfusion Protocols at Level IV Trauma Centers

Early initiation of a high ratio massive transfusion can lower trauma patient mortality by 80%. Long transport times from rural Level IV trauma centers therefore require that damage control resuscitation begin before patient transfer. This study evaluates the current use of fresh frozen plasma (FFP) at Level IV trauma centers and the feasibility of implementing trauma transfusion protocols at these centers. Demographic and clinical data were collected for trauma patients at all state Level IV trauma centers who would have met criteria for massive transfusion protocol (MTP) activation based on the Assessment of Blood Consumption (ABC) score. All state Level IV trauma centers were also surveyed to determine availability of blood bank plasma resources. A total of 760 adult trauma patients presented to a Level IV trauma center during the study period. Three hundred sixty-eight patients (48.4%) were transferred to a higher level of care. Because FAST (Focused Assessment with Sonography for Trauma) results were not available in the state registry data, we included all blunt trauma patients with an ABC score of 1 as "potential ABC-positive patients." Forty-two (5.5%) patients were potentially ABC positive. Fifteen of 22 Level IV centers responded to our survey. Seventy-three percent of respondents have FFP available. Mean time to FFP availability was 63.1 min. Median total length of stay from registration to emergency department discharge for potentially ABC-positive patients was 2 hr. Because most Level IV trauma centers have FFP and thaw times are such that administration would not delay transport to a higher level of care, we recommend implementation of MTPs at Level IV trauma centers to reduce hemorrhage-associated mortality.

Splenic injury admitted to a rural Level 3 trauma centre: a 10-year audit

OBJECTIVE

There is paucity of research documenting the management of splenic injury in rural Australia. No data exists for Rural, Remote and Metropolitan Area 4 locations.

DESIGN

A retrospective review of prospectively collected data. Records were additionally sought from transfer hospitals. A qualitative assessment of splenic trauma management in the Wimmera Region was also performed.

SETTING

Wimmera Health Care Group: Horsham Campus, a Level 3 trauma hospital between January 2000 and July 2011.

PARTICIPANTS

Patients coded with injury of spleen or excision procedure on spleen.

INTERVENTIONS

Nil

MAIN OUTCOME MEASURES

surgical vs. non-surgical management

RESULTS

Nineteen patients were included (mean age 27.8, range 8-54). Only 26% were from Horsham. Most injuries were due to sporting trauma/falls (53%) and motor vehicle accidents (37%). One patient died in theatre from massive trauma. Eleven patients were managed non-operatively. Seven patients had splenectomy performed. Four of these had delay in computed tomography scanning, delay to theatre and suffered major postoperative complication. The age (mean 39.9 versus 20.8) and Injury Severity Score (mean 21.9 versus 13.8) of patients requiring splenectomy was higher than those managed non-operatively. Six of the splenic injury admissions (32%) were transferred from surrounding general practitioner-run Rural, Remote and Metropolitan Area 5 hospitals. All of these patients had Victorian State Trauma Service-defined major trauma with an Injury Severity Score >15. There was an approximate 4-hour delay in transfer of these patients, with transfer occurring when clinical deterioration occurred.

CONCLUSIONS

Although splenic injury is uncommon in the Wimmera region, improved trauma triaging is required, with early transfer of unstable patients and high-energy trauma mechanisms. A lower threshold for computed tomography scanning is recommended.

Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

Background

Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure.

Methods

The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon.

Results

Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources.

Conclusion

Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.

The challenges of developing a trauma system for Indigenous people

Trauma systems have been shown to provide the best trauma care for injured patients. A trauma system developed for Indigenous people should take into account many factors including geographical remoteness and cultural diversity. Indigenous people suffer from a significant intentional and non-intentional burden of injury, often greater than non-Indigenous populations, and a public health approach in dealing with trauma can be adopted. This includes transport issues, prevention and control of intentional violence, cultural sensitization of health providers, community emergency responses, community rehabilitation and improving resilience. The ultimate aim is to decrease the trauma burden through a trauma system with which indigenous people can fully identify.