U.S. Department of Transportation - National Highway Traffic Safety Administration (NHTSA) - The React Project: Rural Enhancement on Access and Care for Trauma - Results - DOT HS 809 521

Most of the data collected in the PMS consisted of frequency counts. The data analysis focused on describing the characteristics of the study sample with frequency distributions of mechanism of injury and types of inappropriate care. In addition, cross tabulation tables were generated for relating categories of preventable death and appropriateness of care to such variables as time of death, cause of death, phase of inappropriate care, and other trauma indicators.

In a before and after fashion, the results of this study were compared with findings of the 1992 PMS. Comparisons of proportions in the cross tabulation tables between this study and the 1992 findings were made with the chi-square test (Tables 4, 14, 15, and 16) and, where appropriate, with Fishers Exact test (Tables 6, 17, 18, 19, 20, 21, and 22). The independent t test was used to compare age and time to death between this study and the 1992 PMS (Table 17). A P value less than .05 was used to define statistical significance.

GUIDELINE COMPLIANCE

Data collected on compliance with the Coalition-approved trauma care guidelines during the intervention year is presented below. Local hospital personnel and EastCare personnel collected the prehospital data on 336 trauma patients. (There is no denominator data available on how many trauma patients were cared for by the prehospital personnel.) The ED data was collected on 548 (53%) of the 1,041 trauma transfers received by the PCMH Trauma Center in the intervention year. The following chart details by hospital the number of prehospital forms submitted and the number of trauma transfer patients for which an ED data collection form was completed.

Overall, there was improvement with time in the prehospital data although there was no statistical significance in the change (Tables 1 and 2). Data collected on ED care showed improvement from quarter 1 to quarters 3 and 4 that was statistically significant (Tables 3 and 4).

Hospital	Number of Prehospital Forms	Number of Trauma Transfers
Albermarle	0	2
Beaufort	8	33
Bertie	11	19
Carteret	29	12
Craven	6	8
Chowan	14	14
Duplin	16	62
Eastcare	20	NA
Halifax	11	34
Heritage	24	34
Lenoir	2	64
Martin	7	21
Nash	6	22
Onslow	0	23
Pitt	68	0
Pungo	1	18
Roanoke-Chowan	4	31
Washington	17	26
Wayne	87	90
Wilson	5	21
Totals	336	548

Table 1. REACT Quarterly and Overall Prehospital Intervention Assessment
*(Percent Accomplished)*
Intervention	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Average
Airway Secured	62.5	44.4	50.0	63.6	55.9
Cervical Spine Immobilized	93.0	97.2	92.7	90.9	93.6
Oxygen Delivered at 100%	80.2	84.0	86.0	91.4	84.3
Chest Tube Inserted/Decompressed			00.0	100.0	75.0
Hemorrhage Controlled	93.0	88.9	80.4	70.0	75.4
Vascular Access Obtained	76.4	74.2	80.4	70.0	75.4
Injured Extremities Splintered	77.2	63.0	83.3	78.3	75.6
Wounds Covered	75.6	71.0	76.5	84.4	75.7

**Table 2. REACT Mean Quarterly Prehospital Intervention Assessment**
Quarter	Number of Observations	Mean Percent Accomplished	Standard Error
1	127	82.4	1.92
2	84	81.5	2.35
3	66	85.5	2.99
4	59	84.8	2.96
Total	336	83.2	1.22

Table 3. REACT Quarterly and Overall Hospital Intervention Assessment
*Percent Accomplished*
Intervention	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Average
Airway Secured	80.0	85.7	81.0	89.1	84.0
Cervical Spine Immobilized	84.0	88.5	90.8	97.3	90.0
Oxygen Delivered at 100%	77.2	76.9	91.4	68.7	77.2
Chest Tube Inserted/Decompressed	84.6	100.0	100.0	90.0	93.8
Hemorrhage Controlled	94.3	96.0	98.1	96.7	96.2
Vascular Access Obtained	99.3	97.6	97.3	98.7	98.3
Injured Extremities Splintered	80.3	84.8	92.3	90.9	86.1
Gastric Tube Inserted	35.2	51.7	58.2	53.5	48.4
Foley Catheter Inserted	77.2	79.1	94.9	86.1	83.7
Wounds Covered	78.0	80.0	90.6	95.0	84.8
Tetanus Documented	83.5	90.1	83.6	96.9	88.1
Antibiotics Given	66.7	75.9	88.5	95.6	79.5

**Table 4. REACT Mean Quarterly Hospital Intervention Assessment**
Quarter	Number of Observations	Mean Percent Accomplished	Standard Error
1	151	78.8*	1.64
2	131	84.2	1.70
3	115	88.7*	1.79
4	153	85.4*	1.44
Total	550	84.0	0.83

FINDINGS OF THE
PREVENTABLE MORTALITY STUDY

Sample

The sample consisted of 134 mechanical trauma deaths. There were 93 (69.4%) males and 41 (30.6%) females. The ethnic breakdown included 74 (55.2%) Caucasian, 50 (37.3%) African-American, 8 (6.0%) Hispanic, and 2 Asian. Mean age was 45.6 years (range 6 months - 93 years). There were 109 (81.3%) unintentional and 25 (18.7%) intentional injuries. Blunt injuries occurred in 113 (84.3%) of the deaths and penetrating injuries in 21 (15.7%). Table 5 presents the mechanism of injury. Approximately 80% of the injuries involved motor vehicle crashes (38.8%), falls (21.6%), gunshot wounds (12.7%), or pedestrians being struck (6.7%).

**Table 5. Mechanism of Injury**
Mechanism	Number	Percent
Motor Vehicle Crash	52	38.8
Fall	29	21.6
Gunshot	17	12.7
Pedestrian Struck	9	6.7
Construction	6	4.5
Assault	4	3.0
Motorcycle Crash	4	3.0
Bicycle Crash	4	3.0
Stab Wound	4	3.0
Carbon Monoxide	2	1.5
Lightning	1	<1.0
Watercraft	1	<1.0

Preventable Deaths and Inappropriate Care

In Table 6 we present the type of care by preventable death rate for all cases. Of the 134 deaths, 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)

**Table 6. Type of Care by Preventable Death Rates for All Causes**
	Preventable		Possibly Preventable		Non Preventable		Total
Type of Care	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Appropriate	0	0.0	0	0.0	92	80.7	92	68.7
Inappropriate	2	100.0	18	100.0	22	19.3	42	31.3
Total	2	1.5	18	13.4	114	85.1	134	100.0

Preventable death rate stratified by time to death, age, and cause of death is presented in Tables 7 and 8. Death occurred within 48 hours in 95 (70.9%) of the fatalities, and 85 (63.4%) of the fatalities occurred in patients less than 55 years of age. Over 70 percent of the deaths were related to central nervous system (CNS) injuries, hemorrhage, or airway injuries. For these causes of death, 4 (26.7%) of the airway, 4 (17.8%) of the hemorrhages, and 3 (9.2%) of the CNS related injuries were judged preventable or possibly preventable.

**Table 7. Preventable Death Rate by Survival Time and Age**
	Time to Death				Age
	<48 Hours		>48 Hours		<55		>55
Preventable Death Rate	Number	Percent	Number	Percent	Number	Percent	Number	Percent
Preventable	1	1.0	1	2.6	2	2.4	0	0.0
Possibly Preventable	11	11.6	7	17.9	10	11.8	8	16.3
Non-Preventable	83	87.4	31	79.5	73	85.8	41	83.7
Total	95	70.9	39	29.1	85	63.4	49	36.6

**Table 8. Preventable Death Rate and Cause of Death**
	Preventable		Possibly Preventable		Non Preventable		Total
Cause of Death	Number	Percent	Number	Percent	Number	Percent	Number	Percent
CNS Injury	0	3.7	3	5.5	52	94.5	55	41.0
Hemorrhage	1	6.7	3	11.1	23	85.2	27	20.2
Airway	1	6.7	3	20.0	11	73.3	15	11.2
Sepsis	0	0.0	1	20.0	4	80.0	5	3.7
Indeterminate	0	0.0	3	20.0	12	80.0	15	11.2
Other	0	0.0	5	29.4	12	70.6	17	12.7

In Table 9 we present the preventable death rate by the place of death. Only 13 (9.7%) of the total fatalities occurred in the operating room or hospital floor, and only two of those were judged preventable. Of the remaining 18 preventable deaths, 9 occurred in the emergency department and 9 in the intensive care unit.

**Table 9. Preventable Death Rate by Place of Death**
	Preventable		Non Preventable		Total
Place of Death	Number	Percent	Number	Percent	Number	Percent
ED	9	45.0	51	44.7	60	44.8
OR	1	5.0	6	5.3	7	5.2
ICU	9	45.0	52	45.6	61	45.5
Post ED	1	5.0	5	4.4	6	4.5

In Table 10 we present the phase of inappropriate care and the preventable death status for those cases. About one-third of the patients had inappropriate care administered at more than one phase of their treatment. Inappropriate care occurred at the emergency department in 19 (45.2%) of the cases, at the prehospital phase or emergency department in 10 (23.8%) of the cases, and the intensive care unit in 4 (9.5%) of the cases.

Table 10. Preventable Death Rate by Phase of Care
When Care Was Inappropriate (N = 42)
	Preventable		Non Preventable		Total
Phase of Care	Number	Percent	Number	Percent	Number	Percent
ED Only	8	40.0	11	50.0	19	45.2
Prehospital Only	0	0.0	5	22.7	5	11.9
Prehospital and ED	3	15.0	2	9.1	5	11.9
ICU Only	4	20.0	0	0.0	4	9.5
Other Phase Combinations	5	25.0	4	18.2	9	21.4

In Tables 11, 12, and 13, we present the type of inappropriate care at the prehospital, emergency department, and post emergency department phases of care. During the prehospital phase, airway management was the leading type of inappropriate care. Other types of inappropriate care included air medical transport access, oxygen/ventilation problem, fluid resuscitation, and unnecessary or deleterious medication. The most frequently documented types of inappropriate care occurring in the emergency department included airway control, failure to recognize an injury, fluid resuscitation problems, chest injury treatment, and delay in going to surgery. During the post-emergency department stage of care, the most frequent type of inappropriate care was related to oxygen/ventilation.

Table 11. Inappropriate Care at the
Prehospital Stage (N = 11)
Type of Inappropriate Care*	Number	Percent
Airway Management	6	54.5
Air Medical transport Access	1	9.1
Oxygen/Ventilation	1	9.1
Fluid Resuscitation	1	9.1
Unnecessary/Deleterious Medications	1	9.1
Other	1	9.1

Table 12. Inappropriate Care at the
Emergency Department Stage (N = 27)
Type of Inappropriate Care*	Number	Percent
Airway Control	7	25.9
Failure to Recognize Injury	7	25.9
Fluid Resuscitation	5	18.5
Chest Injury Treatment	5	18.5
Delayed Surgery	5	18.5
Oxygen/Ventilation	4	14.8
Other Stablization/Treatment	4	14.8
Unnecessary/Deleterious Medications	3	11.1
Failure to use Xray/CT	3	11.1
Surgeon Notified	2	7.4
Inappropriate Operation	2	7.4
Failure to Use Peritoneal Lavage	1	3.7
Labs Sent	1	3.7
Other Operative	1	3.7

Table 13. Inappropriate Care at the
Post Emergency Department Stage (N = 13)
Type of Inappropriate Care*	Number	Percent
Oxygen /Ventilation	4	30.8
Other	4	30.8
Unnecessary/Deleterious Medications	2	15.4
Treatment of Re-bleeding	1	7.7
Monitoring/Management of Head Injury	1	7.7
Ventilatory Care	1	7.7

In Table 14, we present the association between where the fatality occurred and whether treatment was provided by a trauma center, rural hospital, or at a trauma center after treatment occurred elsewhere. Initial treatment at a trauma center occurred in 32 (24%) of the cases, at a rural hospital in 55 (41%) of the cases, and 47 (35%) were transferred to a trauma center. Over 90 percent of all the deaths occurred in either the emergency department or the intensive care unit. There were significantly more deaths in the intensive care unit for transfer cases as compared to trauma center or rural hospital intensive care unit deaths.

**Table 14. Place of Care by Place of Death**
	Trauma Center		Rural Hospital		Transfer to Trauma Center		Total
Place of Death	Number	Percent	Number	Percent	Number	Percent	Number	Percent
ED	10	31.3	42	76.4	8	17.0	60	44.8
OR	4	12.5	3	5.5	0	0.0	7	5.2
ICU	14	43.8	8	14.5	39	83.0	61	45.5
Post ED	4	12.5	2	3.6	0	0.0	6	4.5
Total	32	23.9	55	41.0	47	35.1	134	100.0

In Tables 15 and 16, we compare preventable death rate, type of care, and phase of inappropriate care between trauma center, rural hospital, and transfer cases. Although there were no statistically significant differences, there were more preventable deaths in the rural hospital cases, and more inappropriate care in the rural hospital and transfer cases. In terms of where the inappropriate care occurred, the rural hospitals had more problems during the prehospital care and in the emergency department, while the transfer cases had most of their problems in the emergency department and intensive care unit.

**Table 15a. Place of Care by Preventable Death Rate**
	Trauma Center		Rural Hospital		Transfer to Trauma Center
Place of Death	Number	Percent	Number	Percent	Number	Percent
Preventable	3	9.4	8	14.5	9	19.1
Non-Preventable	29	90.6	47	85.5	38	80.9

**Table 15b. Place of Care by Type of Care**
	Trauma Center		Rural Hospital		Transfer to Trauma Center
Type of Care	Number	Percent	Number	Percent	Number	Percent
Appropriate	25	78.1	40	72.7	27	57.4
Inappropriate	7	21.9	15	27.3	20	42.6

**Table 16. Place of Care by Phase of Inappropriate Care**
	Trauma Center		Rural Hospital		Transfer to Trauma Center
Place of Inappropriate Care	Number	Percent	Number	Percent	Number	Percent
Prehospital	2	6.3	8	14.5	1	2.1
ED	4	12.5	10	18.2	13	27.7
OR	0	0.0	1	1.8	4	8.5
ICU	0	0.0	2	3.6	5	10.6
Post ED	2	6.3	0	0.0	1	2.1

Comparison of the 1992 and 1997/98 Preventable Mortality Studies

As Table 17 shows, the two study samples were similar in racial distribution, gender, average age, and time when death occurred.

**Table 17. Patient Characteristics by Year of Study**
Characteristic*	Year 1992 N = 151	Year 1997/1998 N = 134
Race % Caucasian	51.7	55.2
Race % African American	45.0	37.3
Race % Other	3.3	7.5
Gender % Male	68.9	69.4
Gender % Female	31.1	30.6
Mean Age	40.2	45.6
Age Range	7 months - 93 years	6 months - 93 years
Time to Death % <48 hours	74.8	70.9
Time to Death % >48 Hours	25.2	29.1

In Table 18, we show the mechanism of injury in the two studies. The two studies were almost identical in the number of motor vehicle crashes (37.7% vs. 38.8%), while the 1992 study had significantly more deaths related to violence (30% vs. 19%, p=.04).

**Table 18. Mechanism of Injury by Year of Study**
Mechanism	Year 1992 Number	Year 1992 Percent	Year 1997/1998 Number	Year 1997/1998 Percent
Motor Vehicle Crash	57	37.7	52	38.8
Gunshot Wound	28	18.5	17	12.7
Fall	22	14.6	29	21.6
Pedestrian Struck	16	10.6	9	6.7
Stab Wound	11	7.3	4	3.0
Assault	7	4.6	4	3.0
Other	10	6.6	22	16.4

In Table 19, we show a comparison of preventable death rates and, in Table 20, a comparison of inappropriate care for the two studies. There were significantly more preventable deaths and inappropriate care in the 1992 PMS 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).

**Table 19. Preventable Death Rate by Year of Study**
Preventable Death Rate	Year 1992 Number	Year 1992 Percent	Year 1997/1998 Number	Year 1997/1998 Percent
Total Preventable	43	28.5	20	14.9
Possibly Preventable	32	21.2	18	13.4
Preventable	11	7.3	2	1.5
Non-Preventable	108	71.5	114	85.1

**Table 20. Type of Care by Year of Study**
Type of Care	Year 1992 Number	Year 1992 Percent	Year 1997/1998 Number	Year 1997/1998 Percent
Appropriate	48	31.8	92	68.7
Inappropriate	103	68.2	42	31.3

In Table 21, we show a comparison for the phase of treatment where the inappropriate care occurred. The 1992 study found that both the prehospital and emergency department accounted for over 65% of the inappropriate care, while the 1997/98 study found that the emergency department and post emergency department care were responsible for most of the inappropriate care. There were significantly more incidents of inappropriate prehospital care in 1992 compared to 1997/98 (70% vs. 26%, p=.005).

**Table 21. Phase of Inappropriate Care by Year of Study**
Phase of Care	Year 1992 Number	Year 1992 Percent	Year 1997/1998 Number	Year 1997/1998 Percent
Prehospital	72	69.9	11	26.2
ED	69	67.0	24	57.1
Post ED	35	34.0	17	40.5

In Tables 22 and 23, we show a comparison of the type of inappropriate care at the prehospital and emergency department stages of care. During the prehospital stage, the major type of inappropriate care in both studies was related to airway management. There was significantly more inappropriate airway management in the 1992 study compared to 1997/98 (83% vs. 55%, p < .05). Comparing the types of inappropriate care in the emergency department, airway control, delayed surgery, and failure to recognize an injury were problem areas in both studies. In 1992, too much time in the emergency department or waiting for an X-Ray was found in almost half of the inappropriate cases, while in 1997/98 this was not a problem in any of the inappropriate cases.

**Table 22. Inappropriate Care at the Prehospital Stage by Year of Study**
Type of Inappropriate Care	Year 1992 N = 72	Year 1997/1998 N = 11
Airway Management	83.3%	54.5%
Fluid Resuscitation	15.3%	9.1%
C-Spine Protection	13.9%	0.0%
Oxygen/Ventilation	11.1%	9.1%
Excessive Scene Time	8.3%	0.0%
Air Medical Transport Access	4.2%	9.1%
Unnecessary/Deleterious Medications	0.0%	9.1%

Table 23. Inappropriate Care at the
Emergency Department Stage by Year of Study
Type of Inappropriate Care	Year 1992 N = 69	Year 1997/1998 N = 27
Too Much Time in ED/X-Ray	47.8%	0.0%
Airway Control	21.7%	25.9%
Delayed Surgery	20.3%	18.5%
Failure to Recognize Injury	17.4%	25.9%
Excessive Resuscitation	17.4%	0.0%
Unnecessary/Deleterious Medications	14.5%	11.1%
Chest Injury Treatment	14.5%	18.5%
Diagnostic Resources	13.0%	0.0%
Surgeon Notified	11.6%	7.4%
Oxygen/Ventilation	11.6%	14.8%
Fluid Resuscitation	7.2%	18.5%
Failure to Use X-Ray/CT	5.8%	11.1%
Other Stabilization/Treatment	0.0%	14.8%

Results

DATA ANALYSIS

GUIDELINE COMPLIANCE

FINDINGS OF THE PREVENTABLE MORTALITY STUDY

Sample

Preventable Deaths and Inappropriate Care

Comparison of the 1992 and 1997/98 Preventable Mortality Studies

FINDINGS OF THE
PREVENTABLE MORTALITY STUDY