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L R Tres Scherer, III, MD, FACS
St Luke’s Children’s Hospital
Indiana University School of Medicine
 Rural: everything that is not urban (HRSA)
 What is Urban?
 Populations > 50,000 and/or surrounding
clusters >10,000
...
State Area (km2) width (km) Length (km)
Highest elev
(m)
Lowest elev
(m)
Mean elev
(m) % water
Idaho 216,632 491 771 3860 ...
State Population Density/km2
Interstate
Hwy Total Km Km/Density Counties
Idaho 1,600,000 7.4 3 980 132.4 44
Indiana 6,500,...
 EMS
 Fire
 Search and Rescue
 Forest Service
 Bureau of Land Management
 Aeromedical
State Year Regions
Trauma
Ctrs Level I Level II Level III Level IV Level V Peds I Peds II
Oregon 1987 7 46 2 4 13 25 2
Was...
State Year Registry Hospitals Deaths/Reg Deaths/VS
Oregon 1987 yes 46 558 2700
Washington 1990 yes 89 700 2663
Utah 2000 y...
Esposito, TJ, et al. J Trauma 39:955-62, 1995
 Retrospective panel review of 324 deaths
attributable to mechanical trauma...
UTAH TRAUMA FACILITY STANDARDS
LEVEL I
• Acts as a regional tertiary care facility
in the trauma system.
• Provides defini...
UTAH TRAUMA FACILITY STANDARDS
LEVEL III
• Provides initial resuscitation and
immediate operative intervention to
control ...
TRAUMA ONE ACTIVATION CRITERIA
Physiologic:
 Glasgow Coma score < 12,
 Systolic Blood Pressure < 90 mmHg at any time,
 ...
Pre-transp
location Transport # patients ISS GCS RTS # ICU pts ICU hrs
Transfer Amb 2140 7.26 14.9 7.72 163 26
Transfer Fi...
Pre-transp
location Transport home (%) rehab (%) transfers (%) deaths (%)
Transfer Amb 1854 (99.9) 0 0 1 (.1)
Transfer Fix...
 Unintentional injuries
 964 admissions
 17 hospital deaths
 96 deaths reported to the Health department
 Trauma systems improve access to care
 Pre-hospital
 Trauma center designation
 Improved medical care
 Decrease mort...
 Trauma systems must continue:
 Maturing
 Inclusive
 Evaluate access to care
 Evaluate out of hospital deaths
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state
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Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state

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Pediatric trauma challenges for a rural state

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Day 2 | CME- Trauma Symposium | Pediatric trauma challenges for a rural state

  1. 1. L R Tres Scherer, III, MD, FACS St Luke’s Children’s Hospital Indiana University School of Medicine
  2. 2.  Rural: everything that is not urban (HRSA)  What is Urban?  Populations > 50,000 and/or surrounding clusters >10,000  Census blocks  >1000/400 km2, and clusters >500/400 km2
  3. 3. 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
  4. 4. State Population Density/km2 Interstate 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
  5. 5.  EMS  Fire  Search and Rescue  Forest Service  Bureau of Land Management  Aeromedical
  6. 6. State Year Regions Trauma 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 200810? 8 2 4 0 0 0 1 3 Kentucky 2009 0 10 2 0 2 4 2 Idaho 2014? ? 3 3
  7. 7. 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
  8. 8. Esposito, 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%
  9. 9. 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.
  10. 10. 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.
  11. 11. TRAUMA 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
  12. 12. 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
  13. 13. 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
  14. 14.  Unintentional injuries  964 admissions  17 hospital deaths  96 deaths reported to the Health department
  15. 15.  Trauma systems improve access to care  Pre-hospital  Trauma center designation  Improved medical care  Decrease mortality rate  Mortality rate higher for children in rural areas  More children die outside the hospital
  16. 16.  Trauma systems must continue:  Maturing  Inclusive  Evaluate access to care  Evaluate out of hospital deaths

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