1. Trauma and Stroke Improved Outcomes in Utah Hospitals
A Flex Program Initiative
Don Wood, M.D., Robert F. Jex, RN, MHA, FACHE
The Office of Primary Care and Rural Health, the Bureau of EMS and Preparedness, Utah Department of Health, Salt Lake City, Utah
The Problem
Results- Stroke
Utah is a rural state. 80% of the population lives along the Wasatch Front within 45 minutes of a Designated Primary Stroke Center. But 20% of Utah residents live in rural communities that comprise the other 80% of the state’s geography. Critical Access (CAH) and Rural Hospitals are the primary source of care for this demographic. Nationally, rural areas account for just 20% of the population but 60% of deaths from motor vehicle crashes and increased morbidity and mortality from stroke. Historically rural hospitals have not had systems in place to provide best practice care for time sensitive emergencies of trauma and stroke that patients typically receive in urban hospitals.
Rural and CAH hospitals are designated as Level IV and V trauma centers in Utah. All Level V trauma centers are CAHs and as seen in the first graph, they out perform non-designated hospitals in getting the right patient to the right trauma center for definitive care. Rural EMS agencies and their Level V partners out perform all other EMS agencies and trauma centers with scene times. CAHs which are designated trauma centers also out-perform their non-designated counterparts in transfer times.
The Solution-Program Development
Case Study
With FLEX funding and a partnership with the State Office of Rural Health (SORH), the Utah Bureau of EMS and Preparedness has aggressively pursued the designation of CAH and other rural hospitals as trauma centers and stroke receiving facilities. Of the 27 designated trauma centers in Utah, 10 are rural hospitals—four of those are critical access hospitals. Designated Trauma Centers which are CAHs out perform their non-designated peers in many key performance measures. Rural victims of Time Sensitive Emergencies benefit from a practiced and systematic approach to intervention and treatment. Stroke and Trauma are two conditions where time counts. 25 hospitals have met criteria to become SRFs six of those are Critical Access Hospitals. Door to needle times have been reduced statewide resulting in improved outcomes and survival for stroke patients. FLEX funding has provided Rural Trauma Team Development Course training of EMS and CAH personnel in rural communities.
Sanpete Valley Hospital is a 15 bed CAH in Central Utah. It is a Stroke Receiving Facility having adopted the practiced systematic care for stroke patients. When a patient presented to the hospital unable to speak, he was only able to make babbling sounds during initial examination. The patient had an NIH stroke scale of 8, indicating a stroke had occurred. An emergent CT scan showed a flow void in the left middle cerebral artery. Utah Valley Regional Medical Center (UVRMC) was consulted and rt-PA was recommended. The patient was given rt-PA and transferred to UVREMC where the NIH stroke scale was 3 upon arrival. The patient’s speech and language was also much improved. The patient was admitted to UVRMC. He had resolution of his stroke symptoms by early evening and remained hemodynamically stable. He was discharged from UVRMC the next day without the need for transfer to stroke rehabilitation or long term care.
Conclusions
The Solution-Time Sensitive Care
Results- Trauma
The collaboration between FLEX and EMS in Utah has helped rural and CAH hospitals provide “best practice” treatment for time sensitive illnesses usually found in larger community and urban hospitals. As seen above, stroke and trauma care in CAH facilities rivals outcomes in larger communities and hospitals in the state. The partnership between SORH, FLEX and EMS is making a definitive difference to rural hospitals and the communities they serve.
As hospitals voluntarily become Stroke Receiving Facilities, and designated trauma centers, EMS agencies are encouraged to preferentially transport patients to those hospitals which have become “Stroke and Trauma Ready.” EMS agencies associated with designated trauma centers work with these hospitals to reduce scene times and transport patients to the most appropriate facility.
The four CAH trauma centers in Utah typically out perform their non-designated peers. There are ten state wide filters used to evaluate trauma care in Utah. The charts demonstrate how care is improved when rural facilities apply practiced, systematic care to trauma patients.