developments in rural trauma frederick b. rogers, md, ms, facs medical director of trauma lancaster...
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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.
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