Rural areas encompass approximately 95 percent of the nation’s landmass and have historically been defined as containing fewer than 50,000 inhabitants.1 Unfortunately, trauma care is generally less accessible for those living in rural areas than for their more urban counterparts; 30 percent of Americans in rural areas live more than 30 miles from an American College of Surgeons (ACS)-verified trauma center, and only 24 percent of rural residents live within 10 miles of a trauma center, compared with 71 percent of individuals who live in more urban areas.2 This situation is potentially problematic, as injured patients initially triaged to nontrauma centers have been shown to experience up to a 30 percent higher mortality rate in the first 48 hours after injury,3 and patients in rural areas are twice as likely to die of traumatic injuries than their more urban counterparts.3-6 In addition, more than 50 percent of motor vehicle crash (MVC)-related fatalities occur in rural areas, despite the fact that only about 20 percent of the U.S. population lives there.7
These findings are not unique to MVC-related injuries, as mortality rates are higher in rural areas for falls, burns/electrocutions, accidental firearm injuries, and suicide attempts.6 The underlying mechanism is multifactorial and likely includes remote distance from first responders (or lack of trained personnel/response units), limited trauma volume or experience at rural centers, and the need for multiple patient transfers to reach definitive care.8 One study of an emergency medical services (EMS) system found that increased distance from the injury scene, time on scene, and increased EMS response times were associated with increased mortality in a rural area of Alabama.5 In a 2018 study from Maryland, which has a robust statewide trauma system, the authors found that patients experienced an 8 percent increased likelihood of death for each five-mile increase in distance from a trauma center. This finding was independent of prehospital time, suggesting that mortality is affected by factors other than distance to the receiving facility and may be related to lack of specialized trauma care.9 The odds of death increased by almost 50 percent when the nearest trauma center was a Level III facility.
Rural trauma centers face a number of other challenges, including variability in practices, tertiary care referral and transport logistics, and rural staffing crises.8 In one study of patients transferred to a Level I trauma center from more rural areas, 35 percent had head computed tomography (CT) scans despite the absence of neurosurgical capabilities at the rural facility, 3 percent had aortic arch angiography despite lack of cardiac surgery services, and 5 percent had abdominal CT scans despite documented hypotension.10 All of these issues have the potential to delay transport and negatively affect patient outcome. A 2013 study by Moore and colleagues showed that up to 63 percent of patients transferred to a trauma center required additional imaging, and 28 percent required duplicate imaging.11 Other reports have shown an association between pretransfer imaging and delays in transfer of up to 90 minutes, as well as increased costs without concomitant improvements in outcome.12,13 Staffing also can be challenging, with one study of rural hospitals of 100 beds or less highlighting inconsistencies with emergency department (ED) staffing models and trauma training among covering providers.14
Trauma centers save lives. A 2006 meta-analysis concluded that the implementation of trauma systems has led to a 15 percent reduction in trauma patient mortality.15 That same year, a report in the New England Journal of Medicine compared trauma patient mortality between trauma centers and nontrauma centers, and found that the risk of in-hospital, 90-day, and one-year mortality was lower in trauma centers; these improved outcomes were most pronounced in patients with more severe injuries.16 An increase in the number of trauma admissions per year has been correlated with decreased odds of death in severely injured patients in shock and in a coma.17 Using data from the National Trauma Data Bank®, Brown and colleagues showed that each 1 percent increase in trauma volume was associated with 73 percent increased odds of improved standardized mortality ratio (that is, ratio of observed to expected deaths) over time for patients with an injury severity score (ISS) greater than 15.18 Centers that experienced decreasing volume over time had worse outcomes, suggesting that even experienced trauma centers are affected by decreasing volumes.
Bridging the gap
How can we begin to bridge the gap between rural facilities and trauma centers to improve the care of injured patients? A relatively easy place to start is through education. As Richard K. Simons, MD, said in his address to the 2017 Trauma Association of Canada, “Some authors have reported that some of these mortalities are occurring in-hospital and that injury death rates were threefold higher in regions with limited trauma center access. This would suggest a potential to improve outcomes in rural hospitals through improved education and resource commitment.” Dr. Simons further observed that many rural and remote communities are served by modest health facilities staffed by general practitioners, with little beyond ATLS® (Advanced Trauma Life Support®) capabilities. He noted that survival will now depend on carefully finessed resuscitation practices and timely transfer to a trauma center and that educational needs exceed the principles of ATLS.4
These statements suggest the need for more tailored trauma education that focuses on the specific needs of the rural or resource-limited facility.
The Rural Trauma Team Development Course (RTTDC) was developed by the ad hoc Rural Trauma Committee of the ACS Committee on Trauma (COT). From 2003 to 2015, 821 RTTDCs were offered in 37 states. The course, which also has been presented in 12 other countries, operates under the core principles of reducing the authority gradient among providers who care for trauma patients and providing quality care despite geographic, demographic, training, experience, and limited-resource challenges.19 Overall, the course content is structured similarly to ATLS (that is, primary and secondary survey) but places more emphasis on teamwork/team roles, inter- and intra-facility closed-loop communication, and the logistics of efficient patient transfer.
The idea that most rural EDs can construct a team of three providers, albeit different from that of a Level I center, is emphasized. In addition, rapid stabilization, avoidance of unnecessary imaging, and the decision to transfer patients to a higher level of care within 15 minutes of identifying an injury that exceeds local capabilities, are stressed.19 In this context, the RTTDC is applicable not only to rural hospitals, but to any facility with limited resources or experience in the care of severely injured patients. For example, the Level I trauma center at the University of Pennsylvania, Philadelphia, once received an urban hospital gunshot wound patient who ultimately died of exsanguination a short time after arrival following a 50-minute delay in transfer.
The RTTDC and its lectures, communication videos, and skills stations are structured around the objectives listed in the sidebar. The course is multidisciplinary and applicable across a range of disciplines. Physicians, advanced practice providers (nurse practitioners and physician assistants), nurses, prehospital providers, respiratory therapists, radiology technicians, nursing assistants, and administrative clerks all are encouraged to take and instruct the course. Courses are typically taught over a single day and are conducted on site at the rural or nontrauma center to optimize understanding of local resources (assuming that facilities can accommodate). The RTTDC is considered an outreach function of the Level I or II trauma center, and the rural center should not bear the cost. Most importantly, the course offers significant flexibility and can be tailored to each institution’s needs.
Evidence-supported RTTDC effectiveness
A growing body of literature supports the effectiveness of the RTTDC, especially the course’s impact on processes of care. A 2011 study of 18 Level III and IV trauma centers in West Virginia showed that centers with staff who underwent RTTDC training had a statistically significant 19-minute decrease in decision to transfer times compared with centers where staff had not undergone RTTDC training.20 Centers with RTTDC-trained personnel who also had received specialized communication training decreased decision to transfer times by 37 minutes.
In addition, time from decision to transfer until arrival of the transport team significantly decreased after RTTDC training. In a 2016 pre- and postanalysis comparing six centers where RTTDC training took place with control facilities, Dennis and colleagues found that RTTDC training was associated with a 61-minute decrease in referring facility length of stay (LOS) and a 41-minute decrease in time to initial transfer call.21 No statistically significant difference in pretransfer CT scanning was detected, although there was a trend toward less CT imaging in the RTTDC group (59 percent versus 48 percent). Mortality rates were equal. That same year, another study showed that RTTDC training was associated with a 38-minute decrease in overall transfer times but led to no statistically significant improvements in mortality.7 Referring facility CT imaging was found to delay transfer in both the pre- and post-RTTDC training groups. In a study of rural trauma nurses, the RTTDC was well perceived and associated with improvements in fund of knowledge.22
University of Pennsylvania experience with RTTDC
The Level I trauma center at the University of Pennsylvania facilitated its first RTTDC in April 2018 at an affiliated, nontrauma hospital located more than 30 miles from our campus. Because of the positive reception, we facilitated two additional courses, most recently in April. In total, we have had 46 participants—most of them were registered nurses (see Figure 1). Because of the unique staffing model of the rural hospital at night, where prehospital providers from local EMS personnel often stay to assist with resuscitations, it was important to have these individuals participate in the course as well. Most of the instructors were physicians and advanced practice providers (see Figure 2). With funding from our division, we were able to cover the $40 textbook fee for each student, allowing us to offer the course free of charge (a course expectation). The course does require a significant time commitment from instructors, who do not receive compensation.
Figure 1. Course participants broken down by profession (n = 46)
Figure 2. Course instructors broken down by profession (n = 12)
We refer to the RTTDC as tailored ATLS, because the course can be taught to the specific needs of the rural hospital. Before each course, we identified recent performance improvement (PI) issues that we could specifically address during the course without singling out or blaming any individual. For example, we found a minor issue with chest tube placement, a task that has been associated with increased complications when performed at nontrauma centers.23 We were able to address this issue during the lecture and skills stations related to breathing. We also found that taking time to tour the ED to get a feel for trauma resuscitation logistics (staffing, location of equipment, and so on) was beneficial in identifying areas for improvement. In addition, we added a Bleeding Control course to the “circulation” lecture for supplementary course content and certification. Finally, feedback from course participants helped to facilitate discussions related to trauma care and transfer logistics. For example, one participant expressed frustration related to an isolated incident involving a transfer to our facility, an issue that we were able to address quickly with our transfer center. The flexibility of the RTTDC curriculum allows for these important additions to course content and provides a venue to mitigate process concerns. Ideally, rural centers should leave each RTTDC with a to-do list of items that could be implemented to improve processes of care.
In addition to provider education, the RTTDC helps to strengthen relationships between the rural hospitals and trauma centers, offers Continuing Medical Education (CME) credits, and provides ample research opportunities. We have found participation in the course gratifying for students and instructors alike, and it is constructive for the trauma team to be able to see what nontrauma center health care professionals experience routinely. Although, thus far, we have only had experience with our affiliated institution, the course is applicable to any and all acute care facilities interested in participating.
Course participants have expressed satisfaction with this experience. Of the 46 participants, 41 (89 percent) completed postcourse evaluations. Using a five-point Likert scale (1 = poor/strongly disagree; 5 = excellent/strongly agree), participants reported high scores in all domains (Table 1). These findings are consistent with a previous study of trauma providers from nine rural hospitals, where the RTTDC was positively perceived and found to improve the fund of knowledge.22
Table 1. Participant scores on eight evaluation questions using five-point Likert scale
Quantitative evaluation of course effectiveness
As a pilot study, we sought to evaluate the effects of a single RTTDC on patients transferred to our center from our rural affiliate. After the University of Pennsylvania institutional review board accepted this study as a quality improvement project, we compared baseline and injury-specific characteristics of patients one year before and one year after our first course in April 2018 using descriptive statistics, chi-square/Fisher’s exact test, and Mann-Whitney U test where appropriate. In total, 161 patients were transferred over the two-year period—78 (48 percent) between April 1, 2017, and March 31, 2018 (the precourse group), and 83 (52 percent) between April 4, 2018, and March 28, 2019 (the postcourse group). Overall, most patients (85 percent) were men, had sustained blunt trauma (82 percent), with a median age of 69 years old, and a median ISS of nine. The overall rural hospital ED LOS (as a marker of early transfer) was 258 [184–359] minutes.
When comparing pre- and postcourse groups, no differences were found in baseline characteristics, rural hospital ED LOS, rate of pretransfer CT imaging at the rural facility, trauma center admission vital signs (as a surrogate for adequate rural hospital resuscitation), or disposition from our trauma center ED. No differences were detected in pretransfer blood product use or rate of intubation at the rural facility. We did find a statistically significant difference in the rate of rural facility chest tube placement after specifically addressing this procedure at the first course (0 percent precourse versus 8 percent postcourse, p = 0.007), although we did not compare rates of chest injury or indications for chest tube placement between groups (see Table 2). When looking only at patients with ISS greater than 15 (25 in the precourse group versus 19 in the postcourse group), we did not find a difference in rural hospital ED LOS or trauma center admission vital signs when comparing the pre- and postcourse groups.
Table 2. Comparison of demographic and injury-specific variables between patients transferred from rural affiliate before and after first RTTDC in April 2018
Whereas this was a pilot study, we did not control for confounders by comparing our findings with a control group of similar patients transferred from centers that did not participate in RTTDC training. We suspect that it will be challenging to show improvements in resuscitation and outcomes from our rural facility, given that patients are generally not seriously injured. As we prospectively collect more data after the completion of three courses at the same institution, we hope to at least show significant improvements in processes of care.
Qualitative evaluation of course effectiveness
Although challenging to show quantitatively, we believe this course has led to important improvements in the care of trauma patients at our rural affiliate. At our first course, for example, we quickly determined that the facility did not stock pelvic binders. The facility was able to stock binders within a week, and we were able to facilitate an in-service focusing on device application. In addition, we identified the need for an in-service on lower-extremity traction splint placement and facilitated inclusion of this competency in a registered nurse orientation checklist. Feedback from course participants suggests that the RTTDC has led to important changes in clinical practice, improved relationships with our team, a desire to spread newly acquired knowledge to other providers, and identification of important barriers to change (see sidebar). We anticipate that these changes will translate into improved processes of care and patient-reported outcomes.
Future opportunities: Your help is needed
Aside from rural provider education, the RTTDC model may have other important applications moving forward. As mentioned previously, the course can be used not only in rural or critical access hospitals, but in any facility that lacks the appropriate resources or expertise to deal with seriously injured patients, including international health care centers.24 Future research could focus on the effects of RTTDC on other important processes of care (aside from transfer time), costs, process improvement (PI) metrics, and patient outcomes, including mortality. Undoubtedly, the role of the RTTDC will continue to evolve as models for rural trauma care change over time.
In order for these changes to occur, physician participation will need to increase. One study of providers from 11 community and critical access hospitals who were offered free RTTDC courses with CME credits over a two-year period showed that only 18 of 234 (7.7 percent) participants were physicians, and none were surgeons.25 Although participants—mostly nurses—reported that the course would change their practice, they also cited low attendance by ED physicians and surgeons as a course deficiency. The authors of the study concluded that low physician attendance could be related to schedule challenges and that novel strategies to increase participation are needed.25 Distributing course materials in areas where rural physicians practice and speaking directly with rural ED medical directors prior to course implementation are strategies we have used to improve physician attendance. We believe that physicians who do not routinely practice at trauma centers would find value in the course material.
Physician participation also could help to solidify relationships between the referring center and the trauma center staff, as well as help to identify potential barriers to the resuscitation or transfer processes at the referring facility. Additionally, trauma surgeons at larger centers are just as likely to learn something from their more rural counterparts.
Selected participant commentary from three RTTDCs
- Health Resources and Service Administration. Defining rural population. Available at: www.hrsa.gov/rural-health/about-us/definition/index.html. Accessed June 1, 2019.
- Hsia RY, Shen Y. Changes in geographical access to trauma centers for vulnerable populations in the United States. Health Aff. 2011;30(10):1912-1920.
- Haas B, Stukel TA, Gomez D, et al. The mortality benefit of direct trauma center transport in a regional trauma system: A population-based analysis. J Trauma Acute Care Surg. 2012;72(6):1510-1515.
- Simons RK. Rural accidental injury and death: The neglected disease of modern trauma systems? J Trauma Acute Care Surg. 2018;84(6):972-977.
- Gonzalez RP, Cummings G, Mulekar M, Rodning CB. Increased mortality in rural vehicular trauma: Identifying contributing factors through data linkage. J Trauma. 2006;61(2):404-409.
- Peek-Asa C, Zwerling C, Stallones L. Acute traumatic injuries in rural populations. Am J Public Health. 2004;94(10):1689-1693.
- Malekpour M, Neuhaus N, Martin D, et al. Changes in rural trauma prehospital times following the Rural Trauma Team Development Course training. Am J Surg. 2017;213(2):399-404.
- Adams RDF, Cole E, Brundage SI, Morrison Z, Jansen JO. Beliefs and expectations of rural hospital practitioners towards a developing trauma system: A qualitative case study. Injury. 2018;49(6):1070-1078.
- Jarman MP, Curriero FC, Haut ER, Pollack Porter K, Castillo RC. Associations of distance to trauma care, community income, and neighborhood median age with rates of injury mortality. JAMA Surg. 2018;153(6):535-543.
- Harrington DT, Connolly M, Biffl WL, Majercik SD, Cioffi WG. Transfer times to definitive care facilities are too long: A consequence of an immature trauma system. Ann Surg. 2005;241(6):961-966.
- Moore HB, Loomis SB, Destigter KK, et al. Airway, breathing, computed tomographic scanning: Duplicate computed tomographic imaging after transfer to trauma center. J Trauma Acute Care Surg. 2013;74(3):813-817.
- Emick DM, Carey TS, Charles AG, Shapiro ML. Repeat imaging in trauma transfers: A retrospective analysis of computed tomography scans repeated upon arrival to a Level I trauma center. J Trauma Acute Care Surg. 2012;72(5):1255-1262.
- Onzuka J, Worster A, McCreadie B. Is computerized tomography of trauma patients associated with a transfer delay to a regional trauma centre? CJEM. 2008;10(3):205-208.
- Casey MM, Wholey D, Moscovice IS. Rural emergency department staffing and participation in emergency certification and training programs. J Rural Health. 2008;24(3):253-262.
- Celso B, Tepas J, Langland-Orban B, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60(2):371-378.
- MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378.
- Nathens AB, Jurkovich GJ, Maier RV, et al. Relationship between trauma center volume and outcomes. JAMA. 2001;285(9):1164-1171.
- Brown JB, Rosengart MR, Kahn JM, et al. Impact of volume change over time on trauma mortality in the United States. Ann Surg. 2017;266(1):173-178.
- American College of Surgeons. Rural Trauma Team Development Course. Available at: facs.org/quality-programs/trauma/education/rttdc. Accessed June 1, 2019.
- Kappel DA, Rossi DC, Polack EP, Avtgis TA, Martin MM. Does the rural trauma team development course shorten the interval from trauma patient arrival to decision to transfer? J Trauma. 2011;70(2):315-319.
- Dennis BM, Vella MA, Gunter OL, et al. Rural Trauma Team Development Course decreases time to transfer for trauma patients. J Trauma Acute Care Surg. 2016;81(4):632-637.
- Zhu TH, Hollister L, Scheumann C, Konger J, Opoku D. Effectiveness of the Rural Trauma Team Development Course for educating nurses and other health care providers at rural community hospitals. J Trauma Nurs. 2016;23(1):13-22.
- Jones CW, Rodriguez RD, Griffin RL, et al. Complications associated with placement of chest tubes: A trauma system perspective. J Surg Res. 2019;239(7):98-102.
- Ali J, Kumar S, Gautam S, Sorvari A, Misra MC. Improving trauma care in India: The potential role of the Rural Trauma Team Development Course (RTTDC). Indian J Surg. 2015;77(Suppl 2):227-231.
- Stafford RE, Dreesen EB, Charles A, Marshall H, Rudisill M, Estes E. Free and local continuing medical education does not guarantee surgeon participation in maintenance of certification learning activities. Am Surg. 2010;76(7):692-696.