DEFINITION OF RURAL/FRONTIER

Defining the term rural is actually complicated. Three agencies of the federal government all define it differently. Variables in definitions include the size of the area, whether the area constitutes a county, proximity to an urban area, percentage of residents who commute to an urban area, topography, distances, and available resources. One example of a workable definition is, “A rural trauma region would be an area in which the population served is less than 2500, has a population density of less than 50 persons per square mile, has only basic life support prehospital care, has prehospital transport times that exceed 30 minutes on average, and is lacking in subspecialty coverage for specific injuries (such as a neurosurgeon to manage the patient with head injuries).”¹

Most agree on a definition of a frontier area: “An area with extremely low population density, usually fewer than 6 people per square mile.”² A more complex definition, in the form of a matrix including population density plus distance in time and miles to service/market, has been formulated by the National Clearinghouse for Frontier Communities.³ Northern plains and Rocky Mountain states, along with Alaska, have vast frontier areas. In Montana, one third of the residents live in seven counties. The average population density of the other 49 counties is 2.7 persons per square mile.⁴

UNIQUE NATURE OF RURAL TRAUMA

Obviously, life is very different in rural areas than it is in urban areas. But what urban dwellers usually fail to understand is how different trauma is in the less-populated regions of the world. The people themselves are different. Rural residents tend to be older with more preexisting medical conditions that make recovery from trauma more difficult. Many of these medical conditions are poorly managed, at times because of poverty (rural areas being generally less well off financially than urban ones), and sometimes because of problems with access to care. Overall, rural residents are almost 50% more likely to die of trauma than their urban peers.¹ The rural death rate from motor vehicle crashes (MVCs) is almost twice the urban rate.¹ Of the other 10 most frequent causes of traumatic death, rural rates are higher than urban rates in all but one. Nearly 60% of all trauma deaths occur in rural areas, despite the fact that only 20% of the nation’s population live in these areas. Rural patients who survive longer than 24 hours post-event before dying are older, less severely injured, have more comorbidities and are more likely to die of multiple organ system failure compared with urban patients. Once again looking at Montana, more than 50% of people who die of trauma in that state never make it to the hospital for treatment, usually due to a delay in discovery.⁵

Not only are the people different, but the traumatic events they deal with are different as well. More than 90% of rural trauma is blunt and unintentional.⁶ The majority of critical cases cared for by rural facilities are MVCs, predominately single-vehicle rollovers with ejection. Occupational hazards abound. Farming, ranching, logging, mining, and recreational guiding have high injury rates, and these injuries occur far from facilities providing definitive care. Rural people tend to recreate outdoors, often leading to serious injuries. The incidence of significant injuries from skiing, snowboarding, river recreation, and riding horses, snowmobiles, jet skis, and all-terrain vehicles is on the rise. Time to definitive care is almost always an issue when people are injured participating in these activities. Rural trauma providers sometimes talk about the “golden day” rather than the “golden hour” to reaching definitive care.

PREHOSPITAL CARE

Most rural ambulance services are staffed by volunteers. These civic-minded individuals deal with extremely challenging calls with very little financial or educational support. Call volumes are low and effective performance improvement (PI) programs commonly do not exist, so even those who are most motivated are challenged to provide quality care. Communities typically struggle just to keep an ambulance or two in service and may have limited resources left to invest in quality monitoring and improvement measures.

STAFFING ISSUES

Many rural EMTs actually have to pay to volunteer. Their initial provider course (110 to 120 hours) is usually free, but they are rarely compensated for the hours spent in class or studying away from the classroom. There is rarely compensation for required continuing education. In fact, many EMTs must travel on their own time and pay course or conference fees and travel expenses to receive quality continuing education (CE). Most also have to travel, sometimes great distances, to take certification exams.

The typical rural scenario has volunteers on-call with pagers and/or radios from their homes or workplaces. When a call comes in, they travel to the facility where the ambulance is housed, wait for a partner or two, and then respond to the scene. The time when staffing is most problematic is during the day, Monday through Friday. This is because most volunteers are at their regular jobs during these hours and may not be able to leave, especially when a single ambulance call can take hours to complete.

There are rarely financial incentives to stay involved with the local service. Some are paid a minimal stipend for time actually spent on calls. Even fewer are covered by insurance or have a pension plan. This is a greater problem today than in the past as the rural population ages. Fewer volunteers are signing up to take the places vacated by those leaving the services. It is not uncommon for there to be no one to answer the call.

BARRIERS TO PROVIDING QUALITY CARE

Not only is access to education an issue, but the quality of the education provided can also be problematic in rural areas, especially the farther one gets from the larger communities. Because of the costs of travel, community agencies tend to become self-reliant and provide most of their own education for their volunteers. The lack of involvement by knowledgeable outsiders with current information can lead to stagnation in the messages delivered.

Clearly, the biggest barrier to providing quality care is low call volume. In many rural and frontier services, individual EMTs may have only a couple trauma calls per year. This is especially problematic when these providers have to manage multiple-patient incidents, such as a high-speed, head-on collision between two vehicles on a rural highway causing injuries to four or more individuals. This problem of low call volume is compounded by immature to nonexistent PI programs. Rural EMTs may deliver the patient to the emergency department (ED) and stay to help with resuscitation, but then they go home or back to work. It is very difficult for them, especially in this time when facilities must protect patient confidentiality, to get helpful follow-up information. They may never learn that they missed a life-threatening injury, thereby missing an opportunity to improve their assessments and treatments for their next patient. One might think this should be the responsibility of the service medical director. In a perfect world, every service would have an involved physician leading the team. This is actually a rarity in rural communities. Many rural physicians are already overextended, and many do not possess the knowledge or expertise to mentor EMTs. The combination of limited feedback from facilities and little service involvement by physicians not only results in knowledge deficits for EMTs but is a big reason why many choose not to continue participation after years of service. The sense of isolation can be profound.

A number of system issues unique to the rural/frontier environment become barriers to providing quality care. First, dispatchers frequently lack proper training and protocols, and information passed along to the responding units is often incomplete or inaccurate. Second, locating the patient(s) can be very difficult, especially at night. Many rural residents live on unnamed roads, have unnumbered residences, or both. An ambulance may be dispatched to “the old McClellan place, a brown trailer, up highway 12.” Not only is no actual address given, but the color of the trailer is useless at night. And, the McClellan family may have lived in that trailer for 20 years but has not lived there for the past 5 years. A different family lives there now, but in many parts of rural America the “address” of that home is the name of the family that lived in it for the longest period. Imagine the frustration of the well-intentioned EMT who moved to that community within the last 2 years! The third major barrier is lack of radio communications. Owing to topography, long distances, and insufficient placement of transmission towers, EMTs often cannot communicate with the hospital. They can receive no assistance from medical control, and they cannot alert the facility that they are bringing a critical trauma patient.

NURSE AND PHYSICIAN EDUCATION

One of the greatest challenges facing rural systems is providing quality CE to nurses and physicians. They typically are unable to meet their own needs, because frequently neither the nurses nor the physicians have the time or expertise in trauma care to develop educational modules that fulfill local needs. Plus, the distance between facilities makes it very difficult for outsiders to assist on a regular basis. New technologies, such as web and video links, are being used to solve some of the problems, but many needs remain unmet.

FINANCIAL CONSTRAINTS

Most rural facilities are struggling financially. Education budgets are commonly cut (or eliminated altogether) when facilities endure financial crises. It is difficult for staff members to travel to larger communities for classes or conferences, because these trips usually involve an overnight stay. This is expensive and takes nurses from their families and jobs. It is even difficult for rural facilities to get nurses to attend classes when providers from larger communities come in to provide them. First, when budgets are tight, administrators will not make CE mandatory. Staff must attend on their own time without compensation from the facility. Second, rural facilities are commonly understaffed, so it can be difficult to release nurses to attend classes because they are needed to care for patients. This dilemma could be solved by using traveling nurses, but this can challenge already tight budgets. Educators from regional trauma centers often must present the same class twice in a single community in order for most of the interested nurses to attend. This places a significant burden on the trauma center staff, as they may serve 20 to 30 facilities within their region.

It can also be difficult for rural physicians to leave their practices to attend conferences or Advanced Trauma Life Support (ATLS). The same financial considerations that affect nurses also affect physicians. Furthermore, leaving town can create difficulties in maintaining medical coverage for local citizens. Hiring locum tenens physicians to cover is an option, but is expensive.

MEETING UNIQUE NEEDS

Rural practitioners work in a unique environment, and their educational needs are similarly unique. They often benefit when standard courses are adapted to meet their needs. Further complicating the picture is the fact that different facilities have different needs. One center may encounter chronic delays in getting patients transferred to definitive care, whereas another may be admitting patients who should be transferred. Unfortunately, PI programs specific to trauma are usually immature in rural facilities, and the providers might not even recognize the existence of patient care or system dilemmas.

Using grant monies and telemedicine has helped solve many of these rural trauma education problems. State and national groups are working to improve access to quality education. Much of the burden will continue to be borne by the regional trauma centers, which must accept responsibility for assisting the smaller facilities in their respective regions.

LIMITATIONS ON HOSPITAL RESOURCES

The overall financial performance of the nation’s rural hospitals has improved; however, small rural hospitals (those having 50 beds or less) continue to be at risk of financial instability and closure. Representing about half of all rural hospitals, small hospitals as a group report substantial negative operating margins and are highly dependent on Medicare as a source of payment. Medicare pays for almost 50% of all hospital discharges in rural areas, compared with 37% for urban hospitals.⁷ Rural hospitals typically have lower Medicare margins than urban hospitals. Rural hospitals tend to provide relatively more outpatient and postacute care, and relatively less inpatient care. Therefore, low Medicare payments (relative to costs) for outpatient services are not as easily compensated by inpatient payments. Also, the ratio of total Medicaid days to total days has a significant contribution to hospitals’ financial performance, because hospitals with a higher proportion of Medicaid patients will get additional payment through the Medicaid disproportionate hospital share (DSH) payments system. Rural hospitals are in a disadvantaged position to receive DSH payments because most Medicaid patients are located in the large metropolitan areas and inner cities. Our empirical findings suggest that rural hospitals generate less revenue per bed than urban hospitals.⁷

One of the main reasons rural facilities are struggling is difficulty in managing costs. Between 1990 and 1999, rural hospitals’ cost increases have consistently been one to two percentage points higher than those of urban hospitals, and the cumulative change in cost per case was nearly 30% for rural hospitals and just 14% for urban hospitals.⁸ Though much of this cost differential can be linked to economies of scale, a large part appears to have been caused by smaller reductions in length of stay.⁸

This financial picture is one of many reasons it can be difficult to recruit and retain nurses and physicians in rural areas, causing major challenges in caring for trauma patients. Though many physicians love the rural lifestyle and work environment, many others feel more at home in cities with larger hospitals, more resources, and less sense of professional isolation. Many rural physicians who receive trauma patients in their facilities have never taken ATLS. It can be very difficult for them to attend courses and conferences because of travel costs and the stress of leaving their practices uncovered. Recruitment and retention can be problematic, even if a physician or nurse wants to accept a position, if there are few employment opportunities for his or her spouse or good educational opportunities for children.

Rural practitioners must be the proverbial jack-of-all-trades, working with nursing home patients at the start of the day, later moving to obstetrics to deliver a baby, then going to the ED for trauma resuscitation. Rural nurses, even recent graduates, must at times care for critically injured patients without benefit of trauma training or in-services. Because of weather, distances, and delay in discovery, it is common for their patients to arrive many hours after their traumatic event. Their diagnostic equipment is rarely state-of-the-art, and supplies can be limited, especially in multiple-patient events. It is a challenging work environment.

IMPROVING RURAL TRAUMA CARE

PREHOSPITAL

The report of the Institute of Medicine (IOM) of the National Academies Committee on the Future of Emergency Care in the U.S. Health System offers the following conclusion: “Much progress has been made in the improvement of the nation’s (emergency medical services [EMS]) capabilities. But in some important ways, the delivery of those services has declined.… (T)he committee’s overall conclusion… is that today the system is more fragmented than ever, and the lack of effective coordination and accountability stand in the way of further progress and improved quality of care.”⁹ So, how can we move toward a more integrated and accountable system that is affordable and sustainable and meets the needs of our communities? The recommendations that follow are from both the IOM report and from the National Highway Traffic Safety Association (NHTSA) “EMS Agenda for the Future.”¹⁰

Both groups feel that an important step in addressing the lack of coordination and accountability in emergency and trauma systems is establishment of a lead federal agency for emergency and trauma care. Responsibility is currently scattered among several agencies, including Health and Human Services (HHS), Homeland Security, and the Department of Transportation. The IOM feels this agency should be housed in HHS and should have primary responsibility for trauma and emergency care from dispatch through hospital resuscitation. Each state should have a paid EMS Medical Director, and the American Board of Emergency Medicine should create a subspecialty certification in EMS. HHS should also convene a panel to develop evidence-based indicators of emergency care system performance, and the lead agency should have accountability for their implementation. There must be better coordination within EMS, as well as improved coordination between EMS and public health agencies, especially in disaster preparedness.

In order for EMS to meet the ever-increasing demands on its resources, the payment structure must be changed. Especially in rural areas, where a higher percentage of patients transported are elderly, Medicare is an important payor. Payment for transports is marginal at best, but this is only part of the problem. EMS agencies spend a lot of money maintaining readiness, and current payment schemes do not reimburse for these expenses. Both the IOM and NHTSA recommend including readiness costs and permitting payment to EMS agencies without transport.

One of the goals of EMS trauma care is getting the patient to the right facility in the right amount of time. This can be very problematic in rural/frontier areas, as EMTs often must decide whether to transport a patient (or patients) to a closer but less prepared facility, or to take more time to transport directly to a designated trauma center. Under the current “system,” hospital staff commonly do not know the capabilities of the EMS agencies in their areas, and the EMTs do not know the overall capabilities of the facilities, let alone their ability to accept patients at any given time. Clearly, there must be more precise categorization of EMS agencies and hospitals so more informed decisions can be made. Once this categorization is complete, the next step would be development of evidence-based protocols for movement of patients throughout the system based on patient acuity and facility capability and capacity.

The education and training requirements for both basic and advanced EMTs vary not only from state to state, but sometimes within individual communities. Different agencies may offer courses of varying length and with uneven standards for completion. Standardization of curriculum, scope of practice, and state licensing standards is a goal that would improve patient care and increase the professional standing of EMS personnel.

As discussed earlier, communication in rural areas is commonly problematic. As stated in the IOM report, “hospitals, trauma centers, EMS agencies, public safety departments, emergency management offices and public health agencies should develop integrated and interoperable communications and data systems… HHS should fully involve prehospital EMS leadership in discussions about the design, deployment and financing of the National Health Information Infrastructure.”⁹

The number of air medical helicopters operating in the United States has tripled in the last 15 years. Many operate independently. There are safety and operational concerns as some of these programs operate outside the realm of local systems with no involvement in system-wide PI. Less than 50% of air medical transport agencies are accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS). Many programs suffer from a lack of involved, qualified medical direction. States should assume regulatory oversight of medical air services, including communications, dispatch, and transport protocols.

EMS has lagged behind other public safety entities in disaster planning and operations. EMS must be placed on the same level as these other entities, because few other system components will be able to function effectively if EMS fails. Per the IOM report, “Congress should substantially increase funding for EMS-related disaster preparedness through dedicated funding streams… the professional training, continuing education and credentialing and certification programs for all relevant EMS professional categories should incorporate disaster preparedness training into their curricula and require the maintenance of these skills.”⁹

A model EMS system must recognize the unique needs of pediatric patients. The pediatric patient should always be considered when developing prehospital protocols, planning for disasters, creating performance improvement programs, and in the structure of any agencies that have jurisdiction over EMS services. All providers should receive specialty pediatric training and should have all necessary pediatric-specific equipment. Large gaps in the research arena relative to pediatric emergency care must be filled. Programs such as Emergency Medical Services for Children (EMS-C) that support quality care for children and injury prevention programs must be funded, and all hospitals and EMS agencies that care for injured children should have a staff member responsible for quality oversight in this area.

Both the IOM and NHTSA recognize a critical need for research in EMS, and nowhere is this more needed than in rural/frontier areas. An analysis of current needs should be undertaken, followed by formulation of a strategy to organize and fund research. The emphasis of this research should be on systems and outcomes. Towards this end, the IOM recommends that Congress establish 10 demonstration sites, appropriating $88 million over 5 years, to determine “which strategies work best under which conditions.”⁹ It is imperative that rural providers be active in establishment of this project to ensure some of these sites are in rural/frontier areas.

Our nation needs an emergency care system that is coordinated, regionalized, and accountable. Nowhere is the need greater than in rural/frontier areas. The results of efforts to establish effective, sustainable trauma systems in rural states have been largely disappointing. These efforts, though at times successful, have been plagued by intermittent funding, political/financial turf battles, complaints about rigid federal constraints and the difficulties of conducting research on patient outcomes.

In 1990 Congress allocated federal funding in support of the Trauma Care Systems and Development Act, with the goal of developing a Model Trauma Systems plan. The plan was developed under the direction of staff at the Health Resources and Services Administrations with input from a coalition of trauma systems experts.¹⁰ In 1993 Bazzoli et al. conducted a survey of trauma system administrators to evaluate trauma systems status. “We found that, although many states had made progress by 1993, most had a long way to go to develop comprehensive trauma systems.”¹¹ During this period when federal funding for trauma system development was sporadic, efforts were complicated by a national decline in health care reimbursement that put financial pressures on states, communities, and hospitals, especially in poorer rural areas. Much of the hard-earned momentum from the early 1990s was lost as financially strapped urban facilities relinquished their trauma center designations.

One of the primary functions of a statewide trauma system is to oversee the initiation of standardized protocols designed to ensure the timely triage and transfer of severely injured patients to facilities with appropriate therapeutic resources.¹² Many rural states have no trauma system or designation of facilities. States without trauma systems typically do not have protocols governing either the initial triage or subsequent transfer of patients, or the means by which they are transported. They lack oversight, regional or statewide PI, and educational support for local providers.

Some rural states have established inclusive systems, “designed to care for all injured patients and involve all acute care facilities to the extent that their resources allow, as opposed to exclusive systems, in which care is formally organized only at a relatively few high-level centers that deliver definitive care.”¹³ No data exist to support which system is best suited for urban versus rural environments. Those who advocate for inclusive systems feel that, because of the vast distances separating tertiary care facilities, efforts must be made to improve trauma care in all facilities, no matter how small.

Certain components of trauma systems have proven to be of value, yet no study has been able to prove or disprove the hypothesis that a statewide system leads to better outcomes for patients injured in rural/frontier environments. Nor are there data to support which type of system (inclusive vs exclusive) should be established by those states choosing to build one. Additional research is needed to address these issues.

There are many challenges in improving rural trauma care.¹⁴