Developments in Rural Trauma

Frederick B. Rogers, MD, MS, FACS

Medical Director of Trauma

Lancaster General Hospital

OUTLINE

1. Geopolitics of Trauma Care

2. National perspective on trauma care in 2014.

3. What is the state of rural trauma care in 2014?

4. Critical Access hospitals – what are they? How do they fit in?

5. One man’s opinion.

OVERVIEW

The State of Trauma Systems

• Culture• Politics• Epidemiology• Geography

Culture

We are incredibly diverse!

Sports...

Politics

We are fiercely independent!

“All politics is local!”

Speaker of the House Tip O’Neal

Epidemiology

We are rapidly changing!

Slide of NTDB vs. MTOS outcome

Geography

We are huge!

Rural vs. Urban Geography

National Perspective

Findings of the Institute of Medicine Special Task Force on Emergency Care

National Perspective

A System in Turmoil

• Emergency Department Overcrowding• Fragmentation of Care• Emergency Medical Services Crisis• A Shortage of Specialists• Insufficient Disaster Preparedness• Pediatric Care Most Affected

Rural Trauma Care

… nearly 60% of all trauma deaths occur in rural areas despite the fact that only 20% of the nation’s population live in these areas…

Report on Injuries in AmericaNational Safety Council - 2003

Rural Trauma Care

Rural Trauma Care

The Young

… 87% of rural pediatric trauma deaths did not survive to reach the

hospital…Vane, J Trauma 1995

Rural Trauma Care

… 18% of rural residents are over age 65 compared to 15% of urban residents… rural elders are more often disable and have more occupation related illness compared to their urban counterparts…

The Old

Center for Rural care fact Sheet – University of North Dakota 2003

Rural Trauma Care

The Poor

… poverty and a rural setting are associated with trauma deaths…

Rutledge et al, Ann Surg 1994

Poverty RateRural 15.2%Urban 11.8%

Rural Trauma Care

Risk of Dying: 25% Lower in TC

Rural Trauma Care

Critical Access Hospitals(CAH)*

• Limited bed count to 25• LOS ≤ 4 day limit• 24-hr emergency care services

(focus and stabilizing and transfer to definitive care for, heart attacks, stroke, trauma)

• Must be >35mi. from another hospital

* If they meet these requirements they are eligible to receive cost-based reimbursement from Medicare

Mayo Regional Hospital, Dover-Foxcroft, Maine25- bed CAH hospital

C A H – How did they evolve?

Critical Access Hospitals (CAH)*

•Limited bed count to 25

•LOS ≤4 days limit

•24-hr. emergency care services (focus and stabilizing and transfer to definitive care for heart attack, stroke, trauma)

•Must be >35 mi. from another hospital

*If they meet these requirements,

they are eligible to receive cost-based

reimbursement from Medicare

CAH - Demographics

3/31/11 1327 (22%) of 5808 total hospitals in US

were CAH 45 States now have CAH

1-hr access to level 1 or 2 Trauma Center•24% Rural•86.2% Suburban•95.3% Urban

(ANN Emergency Med, 54(2):261; 2009)

1

2

CAH

1997 Medicare Rural Hospital Flexibility Program (FLEX Program)

*Due to geography, demographics, and access to care, CAH have an integral role in the development of a rural trauma system.

- Fills in geographic gaps

- Stabilize a transfer (analogous to Forward Surgical Station; Battalion Aide Station

in austere environment)

One Man’s Opinion

FUNDING ALREADY AVAILABLE!!

ACS – COT(Rural Trauma Subcommittee)

• Developing standards for Level IV hospitals

• Many will be CAH

One Man’s Opinion

INCLUSIVE: Help all healthcare facilities in delivering the best trauma care possible.

APPROACH: Be consultative and facilitative.

CONSIDER: Local culture, politics, economics.

PRIME DIRECTIVE: Keep the patient at the center of all decisions.

RESOLVE: Never give up.

Are our historical “de facto” rural trauma systems adequate?

•Historically→ YES

•Presently→ ? or NO

Al Qaeda

“Every Muslim’s duty is to kill Americans”Osama bin Laden, 1996

•June 25, 1996: Khobar Towers (US Army Barracks) 19 dead

•Aug 7, 1998: US Embassies: Dar es Salaam, Tanzania

Nairobi, Kenya

• 224 dead

•October 12, 2000: USS Cole 12 dead

Now the Paradigm is Shifting

September 11, 2001

World Trade Center Towers Pentagon

New York City Washington, DC

Individuals

Non-State Actors

State Actors

Risk Assessment

All Communities

High-Risk Visibility Targets

Could it happen in our Rural Community?Homeland Security→ YES!

Terrorist Rationale for a Rural Strike:•“soft” target•“austere” environment—locations where aspects of political, social, physical or economic environment impose severe restraints on disaster response

•Opportunity for hitting multiple targets simultaneously

•High emotional effect (strike the heartland of America)—create a climate of fear and panic

The best preparation for a bioterrorism attack is to have a well-organized trauma system within your state!

Response Preparation

“All politics are local”…as are all disasters.

The concept that the government will swoop down and save the day is fatally flawed.

The government may swoop down but it will take 24-48 hours—by then it may be too late.

Response Preparation

How and Where to BeginHow and Where to Begin

EMS assessment for disaster response.EMS assessment for disaster response.

Rural EMS system is a mile wide and an Rural EMS system is a mile wide and an inch deep.inch deep.

Must take into account there is little redundancy in EMS system locally, but an excellent capacity to cull EMS capability from surrounding communities.

EMS personnel are well-trained in this ability to

respond because they do it on a daily basis.

Response Preparation

Rural Option (Rural) for Triage:

Sacrifice the nearest community hospital

-battalion aid station model

-could be supported by telemedicine

-higher clinical capabilities for triage, acute care

-they have phone, fax, internet, etc.

-ability to shelter from environment

-better staging point

“It is not a question of IF

it will happen.

It is a question of WHEN

it will happen,”

AGAIN.