ATLS adherence in the transfer of rural trauma patients to a level I facility
Introduction
Trauma is the leading cause of death for children and young adults in North America, with a disproportionate number of injuries and deaths occurring in rural settings.1, 2, 3, 4 This is due to a combination of factors that includes higher-risk mechanisms of injury, delayed discovery, limited resources, increased geographic distance from definitive trauma centres and prolonged transport times.4, 5, 6, 7, 8 Regionalized trauma systems, emphasizing resource integration and streamlined transitions in care, have been shown to improve patient outcomes; however even with robust trauma systems in place, there is a threefold increase in the risk of emergency department (ED) death, making the ED an ideal target for intervention in rural trauma care.9, 10, 11
ATLS training provides a framework for the immediate management of the injured patient and has been shown to improve clinical outcomes in both high and low resource settings.12, 13, 14 Accurate assessment and stabilization of trauma patients is of paramount importance, with up to 91% of avoidable trauma deaths estimated to occur during the initial stage of resuscitation.15 In rural and remote areas, the equivalent resuscitative phase is often dramatically lengthened during prolonged transport to first the community hospital and eventually the tertiary centre, underlining the importance of adherence to ATLS guidelines throughout this process.16
Our primary objective in this study was to evaluate ATLS guideline adherence in the management and transfer of acutely injured trauma patients from a range of rural and remote hospitals to a level I trauma centre. A secondary objective was to assess the effect of ATLS adherence on mortality. Ethical, administrative and operational approval was obtained from the University of Alberta and Alberta Health Services.
Section snippets
Methods
We performed a retrospective analysis utilizing data from the Alberta Trauma Registry (ATR) and the corresponding patient charts. The ATR collects data on all trauma patients with an Injury Severity Score (ISS) > 12 who are admitted to one of ten participating trauma centres across Alberta. We studied all admissions to a high-volume academic trauma centre, receiving patients from northern Alberta and British Columbia, the Northwest Territories and Nunavut – one of the largest catchment areas in
Results
Of 768 patients returned in our database query, 646 met our inclusion criteria. 510 (79%) patients were male, with a mean age of 40.5 years. There was a strong predominance of blunt injuries (610 patients, 94%), with the majority due to motor vehicle collisions (MVC). Median ISS was 22 (IQR 16–29). 272 (42%) patients were transported from the peripheral hospital by ground ambulance, with the remainder transferred by fixed wing air ambulance (307, 48%) or rotary air ambulance (67, 10%). The size
Discussion
ATLS protocol adherence has been used as a reliable process measure by which to evaluate quality of trauma care, due to its widespread use and clearly defined guidelines.17 Unfortunately, protocol adherence has been shown to be poor, with rates as low as 43% reported at urban trauma centres.17, 18 Our study supports and extends these findings to the rural setting, where comprehensive patient evaluation and stabilization is of utmost importance due to the prolonged transport required to reach
Conclusions
Our study provides strong evidence that adherence to ATLS guidelines is suboptimal in rural trauma patients transferred to a level I trauma centre. Protocol adherence is slightly higher in more severely injured patients; however there remains significant room for improvement.
Based on our results and the existing literature surrounding rural trauma care, we recommend a comprehensive approach to quality improvement programmes with an increased focus on strengthening the partnership between rural
Conflict of interest
The authors have no conflicts of interest – financial or otherwise – to disclose.
Acknowledgement
The authors would like to acknowledge Dr. Drew Sutherland for his help in the review and preparation of the manuscript.
References (29)
- et al.
A comparison of metropolitan vs rural major trauma in Western Australia
Resuscitation
(2011) - et al.
Clinical impact of advanced trauma life support
American Journal of Emergency Medicine
(2004) - et al.
ATLS practices and survival at rural level III trauma hospitals, 1995–1999
Prehospital Emergency Care
(2002) - et al.
Video assessment of trauma response: adherence to ATLS protocols
American Journal of Emergency Medicine
(1996) - et al.
Factors associated with the higher traumatic death rate among rural children
Annals of Emergency Medicine
(1996) - et al.
Communication during trauma resuscitation: do we know what is happening?
Injury
(2005) - et al.
Teamwork training improves the clinical care of trauma patients
Journal of Surgical Education
(2010) - et al.
Patterns of communication breakdowns resulting in injury to surgical patients
Journal of the American College of Surgeons
(2007) Leading Causes of Death and Hospitalization in Canada
(2005)Injury Prevention and Control: Data and Statistics (WISQARS)
(2011)
Geographic variation in preventable deaths from motor vehicle crashes
Journal of Trauma
Acute traumatic injuries in rural populations
American Journal of Public Health
Rural trauma: the challenge for the next decade
Journal of Trauma
Increased mortality in rural vehicular trauma: identifying contributing factors through data linkage
Journal of Trauma
Cited by (21)
Emergency trauma care in rural and remote settings: Challenges and patient outcomes
2020, International Emergency NursingCitation Excerpt :Research following the introduction of RTTDC found decreased length of stay and earlier transfer acceptance times in rural hospitals [67,113]. Advanced Trauma Life Support (ATLS) training has also been found to improve patient outcomes [8], although lack of adherence to guidelines in rural areas continues to be an issue [68] with wide variation in management evident across a number of studies. Education and training in rural areas enables clinicians to confidently provide initial resuscitation, as well as encouraging collaboration and effective communication with trauma centres [8,99].
Data capture and communication during transfers to definitive care in an inclusive trauma system
2017, InjuryCitation Excerpt :Despite advances in systems of trauma care, injury remains the leading cause of years of life worldwide. Trauma related morbidity and mortality is particularly high in rural areas [1–3]. Survivors of trauma in rural areas who are transferred to urban centres have higher risk adjusted mortality than trauma patients admitted directly to urban centers [4].
Understanding an inclusive trauma system through characterization of admissions at level IV centers
2016, American Journal of SurgeryNontrauma surgeons can safely take call at an academic, rural level i trauma center
2016, American Journal of SurgeryAre the paradigms in trauma disease changing?
2015, Medicina Intensiva