From roadside to bedside: the regionalization of trauma care in a remote rural county.

OBJECTIVE To determine the current role of rural hospitals and prehospital agencies in the care of motor vehicle crash victims in a remote, rural county prior to the statewide regionalization of trauma care. Specifically, we determined the proportion of crashes that required a response by emergency medical services (EMSs), the timeliness of the response, the proportion of patients treated in local hospitals, and the factors that predicted referral to trauma centers. DESIGN Population-based retrospective cohort study linking emergency medical services, emergency department, and hospital discharge data to police motor vehicle crash reports and coroner data. SETTING Okanogan County, Washington. SUBJECTS All motor vehicle occupants, pedestrians or pedalcyclists who were involved in a motor vehicle collision with a response by emergency medical system personnel or the county coroner. INTERVENTION None. MAIN OUTCOME MEASURES EMS response times, emergency department and hospital discharge disposition, Injury Severity Scores, hospital length of stay, procedures, deaths. RESULTS Twelve percent of 669 crashes reported to the police led to the dispatch of EMS. Crashes with EMS involvement were more likely to include occupants without restraints, who were ejected from the vehicle or who had alcohol as a contributing circumstance. The median interval between crash and EMS dispatch was 5 minutes (95th percentile: 40 minutes), the median scene time was 15 minutes (95th percentile: 35 minutes), and the median interval between dispatch and emergency department arrival was 48 minutes (95th percentile: 95 minutes). Among the 210 patients treated by EMSs, 67 (32%) were admitted to local hospitals, and 19 (9%) were referred to a distant trauma center. Of these, 17 were referred directly from the emergency department, one from the scene, and one after local admission. Compared with patients who were admitted locally, referred patients had a significantly higher mean Injury Severity Score (14.4 vs. 5.1), hospital length of stay (9.1 vs. 1.8 days), and rate of operative procedures (37% vs. 9%). Of the 13 crash-related deaths during the year, nine were declared dead at the scene before EMS arrival, three were asystolic at the time of EMS arrival at the scene, and one died at a referral hospital. CONCLUSIONS The linkage of data from police, prehospital agencies, and hospitals can reveal important information about the sequence of health care for trauma patients. The rural hospitals in this county currently play a major role in the stabilization and treatment of motor vehicle crash victims.