L R Tres Scherer, III, MD, FACS

St Luke’s Children’s Hospital

Indiana University School of Medicine

Pediatric TraumaChallenges for a Rural

State

What is Rural?Rural: everything that is not urban

(HRSA)What is Urban?Populations > 50,000 and/or

surrounding clusters >10,000Census blocks>1000/400 km2, and clusters

>500/400 km2

Rural Definition

Rural State Geographic Data

State Area (km2) width (km) Length (km)Highest elev (m)

Lowest elev (m)

Mean elev (m) % water

Idaho 216,632 491 771 3860 217 1520 1

Indiana 94,321 225 435 383 97 210 1.5

Kentucky 104,660 225 610 1260 78 230 1.7

Oregon 255,000 580 640 3429 0 580 2.4

Utah 219,900 435 565 4120 1000 1860 3.3

Washington 184,800 400 580 4392 0 520 6.6

Rural State Population Demographics

State Population Density/km2Interstate Hwy Total Km Km/Density Counties

Idaho 1,600,000 7.4 3 980 132.4 44

Indiana 6,500,000 70.2 8 2076 29.5 92

Kentucky 4,380,400 42.5 5 1147 27 120

Oregon 3,899,300 15 2 1174 78.3 36

Utah 2,855,300 13.2 4 1528 115.7 29

Washington 6,897,000 39.6 3 1230 31.1 39

Pre-Hospital CareEMSFireSearch and RescueForest ServiceBureau of Land ManagementAeromedical

State Year RegionsTrauma Ctrs Level I Level II Level III Level IV Level V Peds I Peds II

Oregon 1987 7 46 2 4 13 25 2

Washington 1990 8 89 1 4 26 33 16 1 2

Utah 2000 0 19 2 3 3 9 1 1

Indiana 2008 10? 8 2 4 0 0 0 1 3

Kentucky 2009 0 10 2 0 2 4 2

Idaho 2014? ? 3 3

State Trauma Systems

State Year Registry Hospitals Deaths/Reg Deaths/VS

Oregon 1987 yes 46 558 2700

Washington 1990 yes 89 700 2663

Utah 2000 yes 19 209 1050

Indiana 2008 yes 43 820 2690

Kentucky 2009 yes 16 365 2264

Idaho 2014? yes (12) 33 (peds) 55 (peds) 224

Trauma System Registries

Pediatric Injuries: ITR and DCO data2006-2011

Pediatric Injuries: ITR and DCO data

ITR EMS Data: Scene and Transport Times

ITR Data: Injury Severity

ITR Data: Hospital Days

Pediatric Injuries: ITR data

ITR and DCO Discharge Disposition

ITR Data: 0-15 y.o, 2006-2011

ITR Data: 0-15 y.o, 2006-2011

DCO Death Data: 0-15 y.o. 2006-2011

DCO Death Data: 0-15 y.o. 2006-2011

DCO Death Data: 0-15 y.o. 2006-2011

DCO Death Data: 0-15 y.o. 2006-2011

ITR Data Quality: Patient Disposition

ITR Data Quality: E-codes

ITR Data Quality: EMS Data

ITR Data Quality

Designation in a Rural StateEsposito, TJ, et al. J Trauma 39:955-62, 1995

Retrospective panel review of 324 deaths attributable to mechanical trauma in the state of Montana

Preventable deaths - 13% Preventable hospital deaths - 27% Pre-hospital deaths - extended response

time 40%; scene time greater than 20 minutes 23%

Inappropriate care in ER - 68% (Inappropriate airway management,

failure to diagnose and treat chest injuries, inadequate volume resuscitation, delays to OR)

In appropriate care post-ER 49%

Esposito TJ, et al. Am Assoc Surg Trauma, Sept 2002

Retrospective panel review of 347 blunt trauma deaths in Montana; comparison to pre-system study

Preventable deaths - 13% to 8% (p < 0.02) Preventable hospital deaths - 27% to 16% Inappropriate pre-hospital care - 37% to 22% Inappropriate care in ER - 68% to 40% (Inappropriate airway management, failure to

diagnose and treat chest injuries, inadequate volume resuscitation, delays to OR)

Inappropriate care post-ER 49% to 29%

Designation in a Rural State

UTAH TRAUMA FACILITY STANDARDS

LEVEL I

• Acts as a regional tertiary care facility in the trauma system.• Provides definitive, and comprehensive care for the injured adult and/or pediatric patient with complex, multi-system trauma.• Provides leadership in professional and community education, trauma prevention, research, rehabilitation and system planning.• Board certified surgeons, neurosurgeons and anesthesiologists are on-call and promptly available. • A broad range of sub-specialists (cardiac surgery, hand surgery, microvascular (replantation), infectious disease) are on-call and promptly available to provide consultation or care to the patient.• ICU physician coverage 24 hours/day, full time Trauma Coordinator, OR suites staffed in-house 24 hours/day, cardiopulmonary bypass.

• Level I Regional Pediatric Trauma Centers have separate standards specific to the care of pediatric Trauma patients.

LEVEL II

• Provides definitive care for complex and severely injured pediatric and adult trauma patients. • Physicians are ATLS trained and experienced in caring for trauma patients. Nurses and ancillary staff are in-house and immediately available to initiate resuscitative measures and stabilization for the trauma patient.• Board certified surgeons, neurosurgeons and anesthesiologists are on-call and promptly available.• A broad range of sub-specialists (critical care, cardiology, orthopedic surgery) are on-call and promptly available to provide consultation or care to the patient.• Serves as a regional resource center for definitive care, quality assurance, community education, outreach and injury prevention.

•Level II Pediatric Trauma Centers have separate standards specific to the care of pediatric Trauma patients.

UTAH TRAUMA FACILITY STANDARDS

LEVEL III• Provides initial resuscitation and immediate operative intervention to control hemorrhage and to assure maximal stabilization prior to referral to a higher level of care. • Comprehensive medical and surgical inpatient services are available to those patients who can be maintained in a stable or improving condition without specialized care.• Works collaboratively with other trauma centers to develop transfer protocols and a well defined transfer sequence.• An in-house multi-disciplinary trauma resuscitation team is available to assess, resuscitate, stabilize and initiate transfer if necessary upon arrival of the patient to the emergency department.• A board certified general surgeon trained in ATLS is on-call and available to the patient.• Level III trauma centers work with Level I and II facilities to develop and implement outreach programs for Level IV and V facilities in their region.• Provides community education, outreach and injury prevention

LEVEL IV• Generally licensed, small rural facility with a commitment to the resuscitation of the trauma patient.•Provides initial resuscitation, evaluation, stabilization, diagnostic capabilities and written transfer protocols in place for major trauma patients to be transferred to a higher level of care.•Staffed with a physician on call from outside the hospital and also requires a general surgeon to be on call outside of the hospital. •May provide immediate operative surgical intervention to control hemorrhage to assure maximum stabilization prior to transfer.•Trauma trained nursing personnel are immediately available to initiate life-saving maneuvers and critical care services as defined in the service’s scope of trauma care.

LEVEL V•Provides initial evaluation, stabilization and transfer to a higher level of care.•Generally licensed, small rural facilities with a commitment to the resuscitation of the trauma patient.•May or may not be staffed with a trauma-trained physicians but rather a physicians assistant, or nurse practitioner.•Major trauma patients are resuscitated and transferred.

Trauma Activation CriteriaTRAUMA ONE ACTIVATION CRITERIA

Physiologic:

Glasgow Coma score < 12,

Systolic Blood Pressure < 90 mmHg at any time,

Respiratory Rate < 8 or > 30,

Revised Trauma Score < 11,

Intubated or question of airway security,

Transferred from outside facility receiving blood products.

Anatomic:

All penetrating injuries to the head, chest, abdomen (including back), or extremities

proximal to the elbow or knee,

Amputation or de-gloving injury proximal to the ankle or wrist,

Flail chest,

Suspected spinal cord injury with paralysis,

Open or depressed skull fracture,

Combination of trauma with burns,

Significant burns (i.e. significant 3rd degree burns, >10% 2nd degree burns TBSA for any age, inhalation burns, etc.)

Clinical:

Discretion of ED physician and/or RN.

TRAUMA TWO ACTIVATION CRITERIA

Physiologic:

Patient age < 5 or > 65 with significant physical impact,

- Pregnancy of 3 months or greater.

Anatomic:

Two or more long bone fractures,

Significant maxillofacial trauma without evidence of airway compromise,

Crush injury proximal to ankle or wrist,

Trauma with burns,

Pelvic fracture (excluding isolated unilateral pubic rami fracture),

Cervical, thoracic or lumbo-sacral spine fracture without CNS involvement,

Major laceration of torso involving fascia,

Subcutaneous emphysema,

Significant burns not meeting Trauma 1 criteria

Mechanism of Injury:

Fall > 20 feet

Pedestrian struck by a vehicle moving > 20mph

MVA with rollover/ejection

Extrication time > 20 minutes

Death in same passenger compartment

Utah Pediatric Trauma: 2006-2011

Pre-transp location Transport # patients ISS GCS RTS # ICU pts ICU hrs

Transfer Amb 2140 7.26 14.9 7.72 163 26

Transfer Fixed 455 13.4 12.5 6.73 204 66.1

Transfer Heli 1019 14.9 11.9 6.5 580 59.2

Field Amb 774 7.44 14.5 7.6 118 52.8

Field Heli 564 12.42 12.8 6.82 183 101.2

Field POV 1334 7.29 14.9 7.68 97 31.7

Utah Pediatric Trauma: 2006-2011

Pre-transp location Transport home (%) rehab (%) transfers (%) deaths (%)

Transfer Amb 1854 (99.9) 0 0 1 (.1)

Transfer Fixed 408 (89.7) 19 (4.2) 3 (.1) 15 (3.3)

Transfer Heli 896 (88) 39 (3.8) 4 (.4) 58 (5.7)

Field Amb 674 (87.1) 5 (.5) 4 (.5) 8 (1)

Field Heli 466 (82.6) 18 (3.2) 5 (.1) 27 (4.8)

Field POV 1334 (100) 0 0 0

Unintentional injuries

964 admissions17 hospital deaths96 deaths reported to the Health

department

Utah Pediatric Trauma: 2010

Trauma systems improve access to carePre-hospitalTrauma center designationImproved medical careDecrease mortality rate

Mortality rate higher for children in rural areas

More children die outside the hospital

Summary

Trauma systems must continue:

MaturingInclusiveEvaluate access to careEvaluate out of hospital deaths

Future