AMBULANCE TRANSPORT PATTERNS FOR ND PEDIATRIC PATIENTS WITH HEAD TRAUMA

Transcription

1 AMBULANCE TRANSPORT PATTERNS FOR ND PEDIATRIC PATIENTS WITH HEAD TRAUMA North Dakota EMSC Advisory Committee Meeting September 16, 23 Presented by: Kyle Muus, PhD, and Dmitri Poltavski, PhD Where: Grand Forks, ND When: Established over 2 years ago Focused on Access, Financing & Quality Through:!Health services research!health policy!education!state & community health services development!information Resource How: Through partnerships

2 BACKGROUND & SIGNIFICANCE Trauma is the leading cause of death and disability in children and young adults. 1 Head injury is the most prevalent category of pediatric trauma. 2 Research has shown that in children sustaining multiple injuries, 8% are diagnosed with head trauma as opposed to only 5% of adults. 3 Approximately 1% of head injuries in children are serious enough to require extensive therapeutic interventions with the remaining 9% being mild. 3 BACKGROUND/SIGNIFICANCE (Cont.) Greater response times have been linked to increased mortality for all age groups. 9 Rural patients with severe injuries were 7 times more likely to die en-route, if the response time was >3 minutes. 1 Pre-hospital times twice as long for rural patients than those in urban areas. 11 MVC study found that 53% of elderly and 48% of pediatric patients with ISS>15 were transported to and received care in non-trauma center hospitals. 12

3 TRAUMATIC BRAIN INJURY (TBI) rapid acceleration & deceleration, including tearing of nerve fibers, bruising of the brain tissue, brain stem injuries and swelling; or, when an external physical force hits the brain, producing an altered state of consciousness, resulting in impaired cognitive abilities, physical/behavioral/ emotional functioning, language and/or memory (CDC, 1999) METHODS ND ambulance data for years Patient Selection Criteria Age: -19 years Body Location of Injury: Head, face, and/or neck GCS: 3-12 Home Base of Responding Ambulance: Rural

4 ISSUES ADDRESSED Patient Demographics Ambulance Run Attributes Seasonal Variation of Injury Occurrence MVCs Patient Demographics, Mechanism of Injury, Contributing Factors Ambulance Transport Destinations: Appropriate (Trauma-Designated) vs. Inappropriate (Not Trauma-Designated) Significant Predictors of Inappropriate Transport History: Effective July 1, General Authority: NDCC Law Implemented: NDCC Local EMS transport plans. (EMS) shall develop local plans for the transport of major trauma patients by appropriate means to the nearest designated trauma center. (EMS) may bypass the nearest designated trauma center for a higher level trauma center provided that it does not result in an additional 3 minutes or more of transport time Source: ND Century Code

5 MacKenzie et al., PATIENT DEMOGRAPHICS

6 FIGURE 1. GENDER FEMALE, 57, 38% MALE, 93, 62% FIGURE 2. AGE DISTRIBUTION % Age

7 FIGURE 3. ETHNICITY Native American, 32, 21% Other, 7, 5% Caucasian, 112, 74% FIGURE 4. GCS DISTRIBUTION % GCS

8 FIGURE 5. MONTH OF YEAR 3 TOTAL MVC 25 2 % JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC FIGURE 6. YEAR %

9 AMBULANCE RUN ATTRIBUTES FIGURE 7. TYPE OF CALL (Dispatch) OTHER, 6, 4% MOTOR VEHICLE CRASH, 7, 46% FALL, 21, 14%

10 FIGURE 8. CPR PERFORMED? YES, 23, 15% NO, 128, 85% FIGURE 9. MILES TO SCENE % Mean=9.4; Median=5; Mode=1; SD=11.7 Miles

11 % FIGURE 1. TIME AT SCENE Mean=12.9; Median=12; Mode=5; SD=7.9 Minutes FIGURE 11. MILES TO DESTINATION % Mean=19.1; Median=11; Mode=1; SD=2.8 Miles

12 MOTOR VEHICLE CRASHES FIGURE 12. MVCs (N=7): Gender Female, 34.3% Male, 65.7%

13 FIGURE 13. MVCs (N=7): AGE % Age FIGURE 14. MVCs (N=7): Ethnicity White 74% Native 2% Other 6%

14 7 FIGURE 15. MVCs (N=7): Mechanism of Injury % Occupant Death in Same MV Intrusion 12"+ Ejection Deformity 2"+ Rollover Speed 4mph % 4 3 FIGURE 16. MVCs (N=7): Contributing Factors Delay in EMS Access *among those aged Extrication > 15min Weather Alcohol* No Seat Belt

15 35 FIGURE 17. MVCs (N=7): Seating Position % Driver Front Rear Other Unknown TRANSPORT DESTINATIONS

16 FIGURE 18. Transported to a Designated Trauma Center? NO, 29, 19% YES, 122, 81% % FIGURE 19. ETHNICITY WITHIN TRANSPORT CATEGORY 'APPROPRIATE' (N=122) NON-NATIVE NATIVE TRANSPORT TYPE 'INAPPROPRIATE' (N=29)

17 % FIGURE 2. TRANSPORT TYPE WITHIN ETHNIC CATEGORY 'APPROPRIATE' NON-NATIVE (N=119) TRANSPORT TYPE 'INAPPROPRIATE' NATIVE (N=32) LOGISTIC REGRESSION: SIGNIFICANT PREDICTORS Native American Winter Miles to Scene Miles From Scene to Nearest Trauma Center INAPPROPRIATE AMBULANCE TRANSPORT

18 CONCLUSIONS Increased distance to the nearest trauma center was associated with increased likelihood of inappropriate transport Increased occurrence of inappropriate transport during winter months Increased occurrence of inappropriate transport when patient was Native American -- a function of remoteness of Reservations in ND and nondesignation trauma center status of the local hospitals RECOMMENDATIONS Increased Statewide Efforts to: educate health care facility administrators, providers and the public about trauma center designations and their role in promoting quality patient care and safety encourage trauma-designated facilities to maintain their status encourage non-designated facilities to become designated promote the importance and use of trauma transport guidelines and pediatric equipment/ treatment guidelines for ensuring quality patient care and safety in prehospital setting

19 Improved EMS Data Collection/Analysis ~Benefits~ Assist in assessing injury prevention needs at the county and community level Assess the EMS care needs for the vulnerable: children and elders Provides implications for EMS education and curriculum development/configuration Reduced paperwork for providers and DEHS Provides opportunities for improved quality assurance/improvement efforts Assess the appropriateness of trauma treatment/transport patterns Provides valuable information for Federal and State grant proposals Improves opportunities for linking EMS care to hospital patient outcomes Serves as documentation of the value of EMS to society REFERENCES 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (1999). Childhood injury fact sheet. URL: 2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2). Traumatic brain injury in the United States: A report to Congress. URL: 3. Duncan, C. L., & Ment, L. R. (199). Central nervous system Head Injury, in Toulouikian, R. J. (ed): Pediatric Trauma. St. Louis, MO, Mosby, VanRooyen, M. J., Sloan, E. P., Barrett, J. A., Smith, R. F., & Reyes, H. M. (1995). Outcome in an urban pediatric trauma system with unified prehospital emergency medical services care. Prehospital Disaster Medicine, 1, Johnson, D. L., Krishnamurthy, S. (1996). Send severely head-injured children to a pediatric trauma center. Pediatric Neurosurgery, 25, Mazurek, A. (1991). Pediatric trauma: Overview of the problem. Journal of Post Anesthesia Nursing, 6, Seidel, J. S., Hornbein, M., Yoshiyama, K., Kuznets, D., Finkelstein, J. Z., & St. Geme, J, W. (1984). Emergency medical services and the pediatric patient: are the needs being met? Pediatrics, 73, Suruda, A., Vernon, D. D., Reading, J., Cook, L., Nechodom, P., Leonard, D., & Dean, J. M. (1999). Pre-hospital emergency medical services: a population based study of pediatric utilization. Injury Prevention, 5, Morrisey, M. A., Ohsfeldt, R.L., Johnson, V., & Treat, R. (1995). Rural emergency medical services: patients, destinations, times, and services. Journal of Rural Health, 11, Grossman, D. C., Kim, A., MacDonald, S. C., et al. (1997). Urban-rural differences in pre-hospital care of major trauma. Journal of Trauma, Injury, Infection, and Critical Care, 42, Esposito, T.J., Maier, R. V., Rivara, F. P. et al. (1995). The impact of variation in trauma care times: urban versus rural. Prehospital and Disaster Medicine, 1, Sorondo, L., & Baez, A. A. (21). Factors influencing the access of severely injured children and elderly patients involved in motor vehicle collisions to trauma center care. Annual Procedures of the Association for Automotive Medicine, 45, U.S. Census Bureau. (2). North Dakota quick facts from the US Census Bureau. URL: North Dakota Emergency Medical Services for Children. (2). North Dakota EMSC 1999 Hospital Emergency Department Survey Results. Full Report. URL: North Dakota Department of Health (1997). Local emergency medical services transport plans. Trauma System Regulation, URL: Loh, J. K., Lin, C. L., Kwan, A.L, & Howng, S.L. (22). Acute subdural hematoma in infancy. Surgical Neurology, 58, Menard, S. (1995). Applied logistic regression. Sage Publications, Thousand Oaks, CA. 18. Al-Ghamdi, A.S. (22). Using logistic regression to estimate the influence of accident factors on accident severity. Accident Analysis and Prevention, North Dakota Department of Health. (23). ND Trauma System National Resource Center on Native American Aging at the University of North Dakota (1999). Rural Native American elders use of ambulance services for medical illnesses, MacKenzie, E.J., Hoyt, D. B., Sacra, J. C., Jurkovich, G. J., Carlini, A. R., Teitelbaum, S. D., Teter, Jr, H. (23). National inventory of hospital trauma centers. JAMA, 289:

20 For more information, contact: Center for Rural Health School of Medicine & Health Sciences Grand Forks, ND