Consistency is Key: Additional Education and Outreach in a Rural Trauma System Reduces Excess Imaging Studies.

BACKGROUND: Repeat imaging for trauma patients is common in rural health care systems after transfer to a tertiary trauma center which subjects patients to increased radiation, excess costs, and delays to definitive care. A previous retrospective review at our regional trauma center found that pre-transfer CT scans were frequently performed with little change in management. To improve this rate, additional emphasis was placed on (1) best imaging practices during Rural Trauma Team Development Courses (RTTDC), (2) management feedback during regional trauma case reviews, and (3) implementation of practice management guidelines for an inter-provider telehealth system. METHODS: Two hundred consecutive adult trauma patients transferred to a regional trauma center were retrospectively evaluated after trauma system improvements were implemented and compared to the previous cohort in the same system as identified by the regional trauma database. RESULTS: 140 (70%) had a pre-transfer CT scan compared to 152 (77.2%) in the prior study (P = .0112). Additionally, 52 (37.1%) of those with pre-transfer CT scans had at least one repeat scan on arrival which decreased from (55.3%) in the prior study (P < .0001). The most common reason for repeat CT scans was incomplete initial imaging. Those with a repeat scan were more likely to have a head injury (51.9% vs 35.8%, P = .0413). DISCUSSION: With regional trauma system maturation and implementation of internal telemedicine guidelines, there was a statistically significant decrease in both pre-transfer as well as repeat CT scans in a rural trauma system. Additional research exploring patient outcomes and cost savings is recommended.

Management of High Grade Splenic Injuries in Rural America.

BACKGROUND: Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products. METHODS: Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality. RESULTS: Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products. DISCUSSION: The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.