Elsevier

Injury

Volume 44, Issue 9, September 2013, Pages 1241-1245
Injury

ATLS adherence in the transfer of rural trauma patients to a level I facility

https://doi.org/10.1016/j.injury.2012.05.009Get rights and content

Abstract

Background

Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility.

Methods

We performed a retrospective analysis of all adult major trauma patients transferred ≥50 km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines.

Results

646 patients were analyzed. Mean age was 40.5 years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253 km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions.

Conclusions

Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.

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.

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