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Introduction

 
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 1992 NHTSA-sponsored RPMS conducted in eastern North Carolina found that specific types of inappropriate emergency medical care may have contributed to the high preventable mortality rate for trauma victims. In that study, 151 rural injury deaths from 1992 were reviewed. Of those deaths, a peer-review panel judged 11 as definitely preventable and 32 deaths as possibly preventable. Combined, these rates produced an overall preventable death rate of 29%.

This high eastern North Carolina rate compared unfavorably with the results of similar studies also sponsored by NHTSA. A 1994 Montana study found an overall preventable death rate of 13% (Esposito et al., 1995). A similar study conducted in Michigan in 1996 found an overall preventable death rate of 12.9% (Maio et al., 1996)

In North Carolina, the 1992 RPMS peer review panel identified that 103 of 151 patients reviewed received some type of inappropriate care. Seventy-two patients had inappropriate care in the prehospital setting and 69 in the emergency department (ED). The 1992 study results suggested that emphasis was needed in two specific areas: 1) the training of prehospital providers in airway management; and 2) the training of hospital providers in the importance of reducing the time to definitive care.

To reduce preventable mortality and inappropriate care, the REACT project instituted a model intervention called STAF. The STAF model was designed to be a 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. It was implemented in eastern North Carolina for a one year period. The intent of the system was to correct deficiencies noted in the 1992 North Carolina Rural Preventable Mortality Study.

The STAF model was implemented as designed 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.

During and following the one-year implementation of STAF, an evaluation was conducted. 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. The details of the intervention and evaluation are presented herewith.

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