As rural hospitals in the US fight to keep their doors open and care for patients in their communities, a session at the ACS Committee on Trauma (COT) Annual Meeting, March 8–10, in Chicago, IL, focused on ways the COT can address the needs of rural providers and patients.
In “Rural Trauma: Injury Care Advanced by Collaboration,” moderated by Michael A. Person, MD, FACS, medical director for the Avera McKennan Trauma Service at the Surgical Institute of South Dakota in Sioux Falls, collaboration between larger trauma centers and rural facilities, as well as trauma system development were discussed.
The need for a true rural perspective within the COT programs was identified a few years ago, when it was acknowledged that most COT members were from large Level I and Level II trauma centers. As a result, the COT Rural Advisory Council, comprising providers on the frontlines of rural trauma care throughout the country, was formed.
Two of these “boots on the ground” providers participated on the panel, describing some of the challenges they face in treating patients in a resource-limited environment. They also offered candid feedback on how the COT and larger trauma centers can better help rural providers and their communities.
Through live polling and panel discussions, several themes arose, including rural provider competency and comfort level in managing injured patients, limited emergency medical services (EMS) and hospital resources, long transport times, liability concerns, and a disconnect in understanding the realities of practicing in a small, rural facility.
Using Teletrauma to Support Providers and Patients
The role of telehealth in trauma—also known as teletrauma—was highlighted in this session and throughout the meeting as an important tool to support providers and patients.
Zain G. Hashmi, MD, assistant professor of surgery in the Division of Trauma and Acute Care Surgery at the University of Alabama at Birmingham and an ACS Associate Fellow, presented an overview of current challenges in rural trauma systems, described the benefits of teletrauma, and outlined practical guidance for implementing teletrauma service.
Millions of rural Americans lack timely access to Level I or Level II trauma center care due to resource constraints. Many Americans are not taken to a facility that appropriately matches their needs. Two distinct challenges exist across the injury severity spectrum.
The first challenge is tethered to transfers in which patients with less severe injuries are transported to a Level I or Level II trauma center and then rapidly discharged from the emergency department after evaluation. Other times, these less severely injured patients have a very short observational stay and are discharged without requiring any further interventions from the higher-level trauma center.
Dr. Hashmi said transfer rates in those situations can be as high as 40%, which can be costly for the patient and hospital system, creating a need to keep some of these patients local.
“In addition to this challenge, rural hospitals also deal with severely injured patients who require a more complex level of trauma care but may experience worse outcomes before the transfer is complete. The question here is how can we improve outcomes for severely injured patients—with the overarching aim to get the right patient to the right place at the right time?” Dr. Hashmi added.
The traditional approach for improving access to care has focused largely on developing additional higher level trauma centers, which is a costly and time-consuming process that has seemed to result in minimal improvement in access to care for the rural severely injured patient.
“In fact, in Alabama, access to a Level I or II trauma center has actually decreased. It’s staggering. More than half of the state’s population does not have access to an ACS-verified trauma center within 60 minutes,” he revealed.
Conceptually, a trauma center is composed of material sources (e.g., blood products, intensive care unit, hemorrhage control devices, trauma bay) and human resources, which broadly can be categorized as procedural and nonprocedural expertise.
“All of this exists within this connected environment, which is simultaneously both a physical space where all the action happens and a virtual space where everybody’s connected using some sort of telecommunications,” explained Dr. Hashmi.
In the context of teletrauma, providers and patients at rural facilities are connected to trauma surgeons and subspecialists at trauma centers with a two-way, real-time audio-video connection.
“The trauma surgeon has access to the patient’s electronic health records, labs, and imaging, as well as a visual on the patient,” Dr. Hashmi said. “And then the nontrauma center has access to key trauma center resources. All of this is intended to facilitate that early point-of-care engagement with topic experts.”
This collaboration of care can help practitioners make decisions that are in the best interest of the patient, leveraging resources that can be readily available via telehealth.
The benefits of using teletrauma for the rural patient, provider, and hospital include:
- Rural patient: Improved outcomes with the ability to stay closer to home and reduce the costs associated with transport
- Rural providers: Increased levels of confidence, connectedness, and access to a forum for real-time education and feedback
- Rural hospitals: Enhanced ability to care for patients in the community, engagement in performance improvement opportunities, and the ability to maintain facility viability
“What does this mean for the trauma system? It means that we are using our resources better and, hopefully, improving patient outcomes,” he said. “I think this goes back to the idea that we are trying to work toward a truly inclusive trauma system.”
Current State of Teletrauma
Dr. Hashmi noted that teletrauma has not found as widespread implementation as other telehealth programs, such as telestroke for improving access to care among rural communities. The challenges associated with wider implementation of this technology include administrative and disease-specific barriers.
Administrative barriers include:
- Funding for infrastructure development
- Costs associated with licensure and liability
- Health information privacy concerns
- Reimbursement for services
“Fortunately, most of these issues have already been addressed by other telehealth services, and there exists precedents and paradigms that we can adapt from quite readily,” Dr. Hashmi said.
Trauma-specific challenges could include:
- Consensus and buy-in from local stakeholders, including providers and patients
- Evidence-based clinical workflow and management protocols
- Trauma-specific telehealth training
- Access to relevant medical supplies (e.g., blood, hemostatics)
- Adoption and integration of telehealth into an existing trauma system
“These are major barriers to progress that have remained largely unresolved with no generalizable solution. There’s no off-the-shelf solution or implementation toolkits, so to speak, that currently address these issues,” said Dr. Hashmi.
Dr. Hashmi described a statewide teletrauma program under development in Alabama that could include up to 26 sites. A majority of rural hospitals have some sort of the telehealth support (e.g., telestroke), which may reduce the costs of teletrauma program implementation. This program could serve as a model for other states and regions once implemented.
“Teletrauma is an alternative solution that may help improve access among injured rural Americans. It looks good on paper, and it makes sense in places that have actually started doing this,” Dr. Hashmi said. “However, there are barriers that need to be resolved before we can study its effectiveness and call for a wider implementation.”
Trauma care in the rural environment faces several challenges. However, education, collaboration, continued trauma system development, along with innovative approaches such as teletrauma, pose opportunities to improve outcomes for injured patients in the rural environment.
More than 400 members of the central and regional Committees on Trauma representing more than 35 countries attended the 2023 COT Annual Meeting, which was open to COT members only. The meeting provided updates from the Advocacy, Quality, Injury Prevention, Systems, and Education Pillars, in addition to a trauma paper competition and Spotlight Discussions—a new networking opportunity organized around specific topics.
