A comparison of metropolitan vs rural major trauma in Western Australia

doi:10.1016/j.resuscitation.2011.02.040

Resuscitation

Volume 82, Issue 7, July 2011, Pages 886-890

https://doi.org/10.1016/j.resuscitation.2011.02.040 Get rights and content

Abstract

Background

Metropolitan and rural Western Australia (WA) major trauma transport times are extremely different. We compared outcomes from these different systems of care.

Methods

Major trauma (Injury Severity Score, ISS > 15) data from the Royal Flying Doctor Service (RFDS) and Trauma Registries, 1 July 1997–30 June 2006. Two groups were studied: Metro (metropolitan major trauma transported directly to a tertiary hospital), and Rural (rural major trauma transferred by the RFDS to a tertiary hospital in Perth). The primary endpoint was death. We used logistic regression and multiple imputation.

Results

3333 major trauma patients were identified (mean age 40.1 ± 22.6 yrs; Metro = 2005, Rural = 1328). The rural patients were younger, had a larger proportion of motor vehicle crashes, and higher median ISS (25 vs 24, p < 0.001). Mean times to definitive care were 59 min versus 11.6 h, respectively (p < 0.0001). After adjusting for age, injury severity and the effect of time with the initial rural deaths, there was a significantly increased risk of death (OR 2.60, 95% CI 1.05–6.53, p = 0.039) in the Rural group. For those rural patients who reached Perth, the adjusted OR for death was 1.10 (95% CI 0.66–1.84, p = 0.708).

Conclusion

There is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.

Introduction

The conventional paradigm of trauma care is that it is a time critical condition.¹ Hence, the ideal system for managing trauma patients is one in which the time from injury to definitive care is minimised.² However, time from injury to definitive care for rural trauma patients is prolonged.³ As such, the ‘golden hour’ of trauma care has little relevance for this population, especially in rural and remote Western Australia (WA).

Mortality from rural trauma increases with delays until discovery of the victim or delays in accessing the trauma system.³ We have previously quantified the direct relationship between remoteness and trauma deaths in WA.⁴ We found that the death rate in very remote areas is over four times the rate in major cities.

This study describes the epidemiology and outcomes of major trauma patients transferred from rural and remote WA by the Royal Flying Doctor Service (RFDS). These data are compared to metropolitan major trauma patients in a population based study. The transport times for these two groups of patients are extremely different and we compared the mortality of these two groups of patients, for those who survive long enough to reach a hospital of definitive care in Perth.

Section snippets

Study design

We obtained data from the RFDS database, on all their major trauma (Injury Severity Score, ISS > 15) transfers to Perth from 1 July 1997 to 30 June 2006. Additional data from the state's Trauma Registries was also obtained, including metropolitan major traumas. The two databases were linked by the WA Data Linkage Branch. Additional data was obtained from the Death Registry and the Australian Bureau of Statistics.

The cohort was divided into two groups. Metro patients were metropolitan Perth major

Results

There were 3333 major trauma patients identified in the nine years of the study. Table 1 describes the demographic and injury data which are significantly different for age, cause and severity. Note that while the rural patients had a higher median ISS, the improved RTS reflects the longer time interval from trauma event to arrival in Perth with the associated period of resuscitation. There were no differences between the groups for anatomic region injured. There was a larger proportion of

Discussion

This population based study reports a comparison between the conventional urban trauma paradigm of the ‘golden hour’ and the unique geographic isolation of rural and remote WA that requires prolonged transport times for definitive care. In general terms, the mortality outcomes reflect age, injury severity and location. However, if a major trauma patient survives to be transferred to Perth by the RFDS, their mortality is equivalent, partly reflecting the ‘self-selection’ that occurs.12, 13

There

Conclusion

In conclusion, we found that there is more than double the risk of major trauma death in rural and remote WA. However, if a major trauma patient survives to be retrieved to Perth by the RFDS, then mortality outcomes are equivalent to the metropolitan area.

Conflicts of interest

There are no conflicts of interest to declare.

Role of the funding source

This study was supported by the Dept of Health, Western Australia, and the Raine Medical Research Foundation. The funding sources had no role in the study design, in the analysis and interpretation of data; in the writing of the manuscript; nor in the decision to submit the manuscript for publication.

Acknowledgements

The authors are grateful for the support of the Data Linkage Branch, Department of Health, Western Australia; and the Trauma Registries at Royal Perth Hospital, Sir Charles Gairdner Hospital, Princess Margaret Hospital and Fremantle Hospital.

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Cited by (68)

The effect of population density on outcomes of major trauma patients in Ireland
2023, Surgeon
Time-sensitive emergencies in areas of low population density have statistically poorer outcomes. This includes incidents of major trauma. This study assesses the effect that population density at a receiving hospital of a major trauma patient has on survival.
Patients meeting Trauma Audit Research Network criteria for major trauma from 2016 to 2020 in Ireland were included in this retrospective observational study. Incident data were retrieved from the Major Trauma Audit, while data on population density were calculated from Irish state sources. The primary outcome measure of survival to discharge was compared to population density using logistic regression, adjusted for demographic and incident variables. Records were divided into population density tertiles to assess for between-group differences in potential predictor variables.
Population density at a receiving hospital had no impact on mortality in Irish major trauma patients from our logistic regression model (OR = 1.01, 95% CI 0.98–1.05, p = 0.53). Factors that did have an impact were age, Charlson Comorbidity Index, Injury Severity Score, and the presence of an Orthopaedic Surgery service at the receiving hospital (all p < 0.001). Age and Charlson Comorbidity Index differed slightly by population density tertile; both were higher in areas of high population density (all p < 0.001).
Survival to discharge in Irish major trauma patients does not differ substantially based on population density. This is an important finding as Ireland moves to a new trauma system, with features based on population distribution. An Orthopaedic Surgery service is an important feature of a major trauma receiving hospital and its presence improves outcomes.
Impact of the Social Determinants of Health on Adult Trauma Outcomes
2023, Critical Care Nursing Clinics of North America
Urban-Rural Inequalities in Care and Outcomes of Severe Traumatic Brain Injury: A Nationwide Inpatient Database Analysis in Japan
2022, World Neurosurgery
Citation Excerpt :
Geographical remoteness and rurality can negatively affect the process of care and outcomes. Previous studies in patients with ischemic heart disease,5,6 stroke,7,8 and general trauma9 consistently showed that outcomes were worse in rural areas than those in urban areas. However, it is unclear whether there are urban-rural inequalities in TBI care and outcomes.
This study aimed to investigate urban-rural inequalities in care and outcomes of severe traumatic brain injury (TBI).
This observational study identified patients with severe TBI from the Japanese Diagnosis Procedure Combination inpatient database from 1 July 2010 to 31 March 2020. The patients were dichotomized into rural and urban groups based on the geographical location of their residence, using the urban employment area scheme. The primary outcome measure was in-hospital mortality. Multivariable regression analyses adjusted for patient-level covariates were performed to compare the outcomes between the 2 groups.
A total of 48,910 patients (rural group, n = 5423; urban group, n = 43,487) were evaluated. In-hospital mortality was significantly higher in the rural group than that in the urban group (49.9% vs. 45.1%; adjusted odds ratio [OR], 1.26; 95% confidence interval [CI], 1.18–1.35). The standardized in-hospital mortality of the rural group was consistently higher than that of the urban group in each fiscal year, and there was no significant trend for closing the gap (P for trend = 0.95). Patients in the rural group were less likely to undergo craniotomy/craniectomy (adjusted OR, 0.83; 95% CI, 0.77–0.89) and intracranial pressure monitoring (adjusted OR, 0.53; 95% CI, 0.46–0.61) and achieve independent activities of daily living at discharge (8.2% vs. 10.5%, adjusted OR, 0.85; 95% CI, 0.76–0.96).
There are significant urban-rural inequalities in TBI in Japan, and the gap in in-hospital mortality has not improved over the last 10 years. Improving TBI care in rural communities may be a target for reducing disparities in health care.
Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015–2019
2022, Injury
In Australia, people living in rural areas, compared to major cities are at greater risk of poor health. There is much evidence of preventable disparities in trauma outcomes, however research quantifying geographic variations in injuries, pathways to specialised care and patient outcomes is scarce.
(i) To analyse the Australia New Zealand Trauma Registry (ATR) data and report patterns of serious injuries according to rurality of the injury location ii) to examine the relationship between rurality and hospital mortality and iii) to compare ATR death rates with all deaths from similar causes, Australia-wide.
A retrospective cohort study of patients in the ATR from 1^st July 2015 to 30^th June 2019 was conducted. Descriptive analyses of trauma variables according to rurality was performed. Logistic regression quantified the moderating effect of rurality on trauma variables and hospital mortality. Australian death data on similar injuries were sourced to quantify the additional mortality attributable to severe injury occurring outside Major Trauma Centres (MTCs).
Compared to major cities, rural patients were younger, more likely to have spinal cord injuries, and sustain traffic-related injuries that are ‘off road’. Injuries occurring outside people's homes are more likely. Mortality risk was greater for patients sustaining severe traumatic brain injury (TBI) spinal cord injury (SCI) and head trauma in addition to intentional injuries. Compared to the ATR data, Australian population-wide trauma mortality rates showed diverging trends according to rurality. The ATR only captures 14.1% of all injury deaths occurring in major cities and, respectively, 6.3% and 3.2% of deaths in regional and remote areas.
Compared to major cities, injuries occurring in rural areas of Australia often involve different mechanisms and result in different types of severe injuries. Patients with neurotrauma and intentional injuries who survived to receive definitive care at a MTC were at higher risk of hospital death. To inform prevention strategies and reduce morbidity and mortality associated with rural trauma, improvements to data systems are required that involve data linkage and include information about patient care from pre-hospital providers, regional hospitals and major trauma centres.
Geographical risk of fatal and non-fatal injuries among adults in Norway
2021, Injury
Introduction: A rural gradient in trauma mortality disfavoring remote inhabitants is well known. Previous studies have shown higher risk of traumatic deaths in rural areas in Norway, combined with a paradoxically decreased prevalence of non-fatal injuries. We investigated the risk of fatal and severe non-fatal injuries among all adults in Norway during 2002–2016.
Methods: All traumatic injuries and deaths among persons with a residential address in Norway from 2002–2016 were included. Data were collected from the Norwegian National Cause of Death Registry and the Norwegian Patient Registry. All cases were stratified into six groups of centrality based on Statistics Norway's classification system, from most urban (group one) to least urban/most rural (group six). Mortality and injury rates were calculated per 100,000 inhabitants per year.
Results: The mortality rate differed significantly among the centrality groups (p<0.05). The rate was 64.2 per 100,000 inhabitants/year in the most urban group and 78.6 per 100,000 inhabitants/year in the most rural group. The lowest mortality rate was found in centrality group 2 (57.9 per 100,000 inhabitants/year). For centrality group 6 versus group 2, the risk of death was increased (relative risk, 1.36; 95%CI: 1.11–1.66; p<0.01). The most common causes of death were transport injury, self-harm, falls, and other external causes. The steepest urban–rural gradient was seen for transport injuries, with a relative risk of 3.32 (95%CI: 1.81-6.10; p<0.001) for group 6 compared with group 1. There was a significantly increasing risk for severe non-fatal injuries from urban to rural areas. Group 2 had the lowest risk for non-fatal injuries (1531 per 100,000 inhabitants/year) and group 6 the highest (1803 per 100,000 inhabitants/year). The risk for non-fatal injuries increased with increasing rurality, with a relative risk of 1.07 (95%CI: 1.02–1.11; p<0.01) for group 6 versus group 1.
Conclusions: Fatal and non-fatal injury risks increased in parallel with increasing rurality. The lowest risk was in the second most urban region, followed by the most urban (capital) region, yielding a J-shaped risk curve. Transport injuries had the steepest urban–rural gradient.
Comparing orthopaedic paediatric trauma in a rural district general hospital and an urban major trauma centre: A retrospective cohort study
2021, Annals of Medicine and Surgery
Citation Excerpt :
A very large 2017 American study (50,000 patients) found no significant difference between mortality in rural vs urban adult trauma, although patients who did die tended to within the first 24 h in rural settings, rather than later in urban major trauma centres [8]. Many other papers [9–13] have reported higher mortality rates for all (adult and paediatric) trauma in rural centres vs urban hospitals, although the major trauma centre status of many of these institutions in cities may account for this. No studies, however, were found which compared the type of trauma, time to theatre, mechanism or specific orthopaedic operations performed in this patient group.
Studies from countries such as Australia and South Africa have demonstrated a difference in the types of injury managed in rural hospitals compared to larger, urban hospitals and so conclude staff require a different skill-set to work in these environments. There is some evidence this attitude may be prevalent amongst UK surgical trainees, resulting in difficulty recruiting to rural settings. In addition, studies have compared mortality in paediatric trauma patients in rural and urban hospitals, but none have described types of injury or orthopaedic operations required.
We hypothesise the distribution of operative, orthopaedic paediatric trauma in a rural district general and an urban major trauma centre will not differ significantly in terms of patterns and mechanism of injury, orthopaedic intervention or time to theatre.
All operative paediatric patients (0–15yrs) seen during an acute orthopaedic take at a rural district general and an urban major trauma centre were included. Non-operative admissions were excluded. Patients were identified using daily trauma work lists from each site. Outcomes were age, injury type, operation, time to theatre, seasonality and mechanism.
183 patients from the urban hospital and 103 from the rural were identified. There were no significant differences found in age of patient, seasonality or time to theatre between cohorts (p > 0.05). There were also broadly similar patterns of injury and operations performed in both groups, although k-wiring was more often employed in the rural cohort than the urban (27% vs 17% of total operations). There were more bicycle and shinty related injuries in the rural cohort, and equine related in the urban.
Paediatric trauma admissions do not vary significantly between rural and urban trauma centres, although the types of procedure performed may be less conservative in a rural hospital. This may be due to geography or differences in ED practice.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.040.

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Clinical paperA comparison of metropolitan vs rural major trauma in Western Australia☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Conclusion

Conflicts of interest

Role of the funding source

Acknowledgements

Emerg Med Clin North Am

Injury

J Am Coll Surg

Lancet

Resuscitation

Int J Surg

Advanced trauma life support for doctors

Rural trauma: the challenge for the next decade

J Trauma

The relationship between remoteness and trauma deaths in Western Australia

J Trauma

A simple sequentially rejective multiple test procedure

Scand J Stat

Applied logistic regression

Assessing response bias from missing quality of life data: the Heckman method

Health Qual Life Outcomes

Clinical paper
A comparison of metropolitan vs rural major trauma in Western Australia☆