The purpose of the Rural Enhancement of Access and Care for Trauma (REACT) project was to reduce episodes of inappropriate emergency medical care and decrease the rate of preventable deaths from injury in rural eastern North Carolina. The project was a follow up to a 1992 National Highway Traffic Safety Administration (NHTSA) sponsored Rural Preventable Mortality Study (RPMS) which found an overall preventable mortality rate for eastern North Carolina of 29%. In response to this high rate, an intervention aimed at enhancing timely access to definitive trauma care and improving the emergency medical care delivered by rural health personnel was implemented and evaluated.
The intervention centered around STAF, a model continuous quality improvement system composed of Standards of care, Training, And Feedback aimed at prehospital and hospital emergency providers of trauma care in rural areas. The STAF model was implemented for the 29 counties in rural eastern North Carolina served by the trauma service of Pitt County Memorial Hospital. This is the same area in which the 1992 RPMS was conducted. There were three components of the intervention phase of the REACT project: 1) partnership with the Eastern Regional Trauma Coalition to develop trauma care guidelines (standards) for the treatment of trauma patients which addressed the deficiencies identified in the 1992 RPMS study; 2) guideline-focused, in-depth training for emergency medical personnel in the region; and 3) feedback to emergency medical personnel on their conformance to the guidelines.
The evaluation had two components: 1) assessment of the compliance with trauma care guidelines during the intervention phase; and 2) determination of the preventable mortality rate for the region during the intervention year to determine if the intervention had an impact.
Overall, there was improvement with time in the prehospital guideline compliance data although there was no statistical significance in the change. Data collected on emergency department (ED) guideline compliance showed statistically significant improvement from quarter 1 to quarters 3 and 4.
Of the 134 deaths in 1997/98, 2 (1.5%) were judged preventable, 18 (13.4%) possibly preventable, and 114 (85.1%) non-preventable. The overall preventable death rate was 14.9%. In 42 (31.3%) of the cases, some aspect of the care was judged inappropriate. All of the cases judged preventable had inappropriate care compared to 92 (80.7%) of the non-preventable cases (p=.0005).
There were significantly more preventable deaths and inappropriate care in the 1992 preventable mortality study compared to the 1997/98 study (29% preventable deaths and 68% inappropriate care in 1992 vs. 15% preventable deaths and 31% inappropriate care in 1997/98, p<.01).
Implementation of the STAF model was associated with a reduction in the rate of preventable trauma deaths compared to the rate found in the 1992 RPMS. The rate for the STAF intervention year was similar to that found in NHTSA-sponsored rural preventable mortality studies conducted previously in Michigan and Montana. We recommend that the STAF model be tested in other locales.
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