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.

Factors Associated with Ocular Injury in Orbital Fracture Patients: Who Requires Urgent Ophthalmic Evaluation?

Importance: Create validated criteria to identify orbital fracture patients at higher risk for significant ocular injuries. Objective: Determine history and physical examination findings in orbital fracture patients who are associated with ocular injury and warrant urgent assessment by an ophthalmologist. Design, Setting, and Participants: Retrospective chart review of 535 adult orbital fracture patients evaluated at a Level I emergency department between 2014 and 2017, without prior history of orbital fracture, ocular injury, or ocular/orbital surgery. Main Outcomes and Measure: Presence of ocular injury. Results: In total, 195 (36%) patients had an ocular injury. Those with and without ocular injury were compared in a multivariate logistic regression model including demographics, fracture characteristics, injury mechanism, and physical examination findings. Visual acuity change, radiographic retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye all had significant associations with ocular injury when other findings were controlled. Conclusion: This study shows a significant association between ocular injury and visual acuity change, retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye. These factors can help triage when to obtain an urgent ophthalmology consult.