Factors Influencing Time to Definitive Care in Hip Fracture Patients in a Rural Health System.

BACKGROUND: Current literature has not adequately addressed factors affecting wait times for hip fracture surgery in the rural setting. OBJECTIVE: This study aims to assess the factors affecting admission, transit, and preoperative wait times that impact the timeliness of hip fracture surgery within a rural health system. METHODS: A single-center retrospective cross-sectional study was conducted in a rural community comprising five community hospitals and two receiving hospitals. A trauma registry study included all hip fracture cases from 2019. Mean, standard deviation, median, and interquartile range were calculated for admission wait times, transit times to the receiving hospitals, and preoperative wait times in hours. Metrics based on means or medians were developed for these wait times. RESULTS: A total of 163 patients met the inclusion criteria. The emergency department wait times before and after admission to the community hospitals were 1 hour and 2.5 hours, respectively. The transit times from the community hospitals, ranging from shorter to farther distances, to receiving hospitals were 40 minutes and 1 hour, respectively. The preoperative wait time for admitted and transferred patients was 12 hours. CONCLUSION: Our study outlines a methodology for establishing wait time metrics that impact surgical timeliness for hip fracture patients within a rural healthcare system. We recommend conducting comparable studies with larger sample sizes across different healthcare systems.

Effectiveness of Multimodal Pain Therapy on Reducing Opioid Use in Surgical Geriatric Hip Fracture Patients.

BACKGROUND: There is a need for appropriate pain control in the geriatric hip fracture population to prevent diminished function, increased mortality, and opioid dependence. Multimodal pain therapy is one method for reducing pain postoperatively while also decreasing opioid use in the geriatric hip fracture patient. This study aimed to determine whether multimodal pain therapy could decrease opioid use without increasing pain scores in surgical geriatric hip fracture patients. METHODS: This was a before-and-after cohort study. The hospital implemented multimodal pain control order sets with a standardized pain regimen and performed retrospective chart review pre- and postorder set implementation for analysis. RESULTS: A total of 248 patients were enrolled in the study: 131 in the preorder set group and 117 in the postorder set group. The mean postoperative oral morphine equivalent (OME) was significantly lower in the postorder set group than in the preorder set group (45.1 mg vs. 63.4 mg, respectively, p = .03). Compared with the preorder set group, total OME and postoperative OME were decreased by 22.6% (95% confidence interval [CI] -44.9, -3.8), 1-tailed p < .01, and 53.6% (95% CI -103.4, -16.1), 1-tailed p <.01 respectively, in the postorder set group. There was not a statistically significant difference in mean pain scores at 6, 24, and 48 hr postoperatively (p = .53, .10, and .99), respectively. CONCLUSION: Implementing a multimodal approach to pain management may help reduce opioid use and may be a critical maneuver in averting the national opioid epidemic.

Improved Survival for Rural Trauma Patients Transported by Helicopter to a Verified Trauma Center: A Propensity Score Analysis.

OBJECTIVES: Recent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting. METHODS: The ascertainment of trauma patients age ≥ 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation. RESULTS: Unadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well-matched data set, HT was associated with a 2.69-fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21-5.97). CONCLUSIONS: In a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings.

Effectiveness of the Rural Trauma Team Development Course for Educating Nurses and Other Health Care Providers at Rural Community Hospitals.

The study evaluates (1) health care provider perception of the Rural Trauma Team Development Course (RTTDC); (2) improvement in acute trauma emergency care knowledge; and (3) early transfer of trauma patients from rural emergency departments (EDs) to a verified trauma center. A 1-day, 8-hour RTTDC was given to 101 nurses and other health care providers from nine rural community hospitals from 2011 to 2013. RTTDC participants completed questionnaires to address objectives (1) and (2). ED and trauma registry data were queried to achieve objective (3) for assessing reduction in ED time (EDT), from patient arrival to decision to transfer and ED length of stay (LOS). The RTTDC was positively perceived by health care providers (96.3% of them completed the program). Significant improvement in 13 of the 19 knowledge items was observed in nurses. Education intervention was an independent predictor in reducing EDT by 28 minutes and 95% confidence interval (CI) [-57, -0.1] at 6 months post-RTTDC, and 29 minutes and 95% CI [-53, -6] at 12 months post-RTTDC. Similar results were observed with ED LOS. The RTTDC is well-perceived as an education program. It improves acute trauma emergency care knowledge in rural health care providers. It promotes early transfer of severely injured patients to a higher level of care.

The lost to trauma patient follow-up: a system or patient problem.

BACKGROUND: The objective of this study was to explore the reasons for trauma patients' failure to follow up at a trauma clinic (TC). METHODS: A 1-year retrospective analysis was conducted on those trauma services patients (n = 799) who were discharged from Parkview Hospital in 2009. Hospital electronic medical records were examined to identify variables of interest; telephone interviews were attempted on those patients who failed to follow up (FTF); and calls were made to the offices of involved subspecialist (SS) to determine if any follow-up had occurred. Data analysis was performed by Microsoft Excel and SPSS. RESULTS: Two hundred thirty-three patients were identified as having FTF in the TC. Patient or external factors caused a follow-up loss for 147 patients (63.1%), and 44% of them did have a follow-up with an SS. Hospital or internal factors resulted in 86 patients (36.9%) being FTF, and 43% of them were seen by an SS. The physician compliance rate per policy was 89.2% (713 of 799). The patient compliance rate at TC follow-up was 79.3% (566 of 713). The total patient compliance rate both at the TC and SS follow-up was 87.2% (669 of 767). No significant demographic differences in age, sex, Injury Severity Scores, hospital payment status, or distance from the hospital were noted between those patients who had FTF in the external or internal factor groups. Of the 130 patients who had no follow-up, 39% did meet follow-up criteria. CONCLUSION: Only 10.8% of the trauma patients who had appointments for any posttrauma follow-up had FTF, implying that the patient is not the reason for FTF but that FTF is a system issue. With improved patient education on the day of hospital discharge and improved physician discharge orders, trauma patient follow-up could approach 100%. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Readmission of trauma patients in a nonacademic Level II trauma center.

BACKGROUND: Readmission of trauma patients has been identified as a quality indicator for trauma care. Few if any studies on this topic can be found from a nonacademic trauma center. The objectives of the study were to determine the rate, cause, and preventability for readmission and to identify predictors of readmission in a nonacademic trauma center. METHODS: Cases registered from 2007 to 2009 were identified from trauma registry. A retrospective chart review of 98 readmission trauma patients was done to elicit the complications and outcomes. Criteria were selected to elicit preventability of readmissions.Predictors for readmission were identified by using a logistic regression analysis. RESULTS: Of 4,986 patients, 98 (1.96%) required readmission due to wound (23.47%), abdominal (16.33%), thromboembolic (4.08%),central nervous system (21.43%), hematoma (5.10%), and pulmonary (7.14%) complications. Among all readmission cases,surgery was performed in 38.78%, days to readmission was 19.44 ± 8.80, and six patients experienced a readmission chain.Penetrating injury, Injury Severity Score 25, and hospital length of stay were predictors of readmission. 90.82% of the trauma readmissions were trauma related and 15% were potentially preventable readmissions. Fifty-three percent of the readmissions occurred before a follow-up appointment. CONCLUSIONS: The incidence of readmissions was similar to published data from academic trauma centers, but the reason for readmission and the need for surgery at readmission were very different. Potentially preventable readmissions have not been well addressed in literature. Therefore, further multicenter studies that include nonacademic trauma centers are needed to analyze this complicated problem.