This is a single center pilot study, utilizing a prospective cohort design that aimed to investigate outcomes related to initial whole blood (WB) resuscitation in a level I rural trauma center. The WB cohort (N=40) was matched with historical controls (HC) (N=153) that included adult trauma activations. Patients in hemorrhagic shock received up to two units of WB, with subsequent transfusions guided by massive transfusion or thromboelastography. Component utilization, time to hemorrhage control, complications, and transfer times were evaluated. The WB group utilized significantly less component therapy than HC (median 0 units vs. 2; P < .0001) and demonstrated decrease in packed red blood cell utilization through the first 24 hours (1.5 vs. 2.0; P = .006) and throughout the entire admission (2.0 vs. 4.0; P = .0003). There were no differences in time to hemorrhage control between cohorts. Overall, patients receiving WB had a lower rate of any complication (35% vs. 55.6%; P = .02), Specific complications such as DVT, cardiac arrest, CAUTI, ARDS, Ventilator, ICU length of stay, and hospital length of stay were also similar. Rates of survival at discharge were 80% for WB patients and 85% for HC patients. The WB group had longer transport time to their center (2.03 vs. 1.42 hours; p=0.002).
There are scant studies on WB utilization in the rural setting, making this study unique. The authors concluded that subsequent transfusions are reduced in the WB group, likely due to the benefits of WB being more physiologic compared to component therapy during hemostasis. This makes for more efficient resource utilization especially in rural centers where there may be more considerable constraints. Furthermore, time to hemorrhage control (including surgery) is similar and complication rates are lower overall, despite prolonged transport times compared to urban centers. This finding also highlighted the need to improve system-level issues in patient transport as delays in WB transfusion may impact its effectiveness. Future directions include studying early access to WB in rural areas with long transport times and to validate findings in a larger cohort.
This is a retrospective review from 2018-2022 to evaluate the outcomes of patients with three or more uncomplicated rib fractures at Level IV trauma centers in the Pennsylvania Trauma System. They stratified patients based on pre vs post 2020 rule change allowing three or more rib fractures to stay at Level IV centers vs transferring to higher level (I/II) trauma centers. Identified a total of 1,070 patients, 360 admitted to Level IV centers, 132 (36.6%) and 228 (63.3%) in the pre- and post-2020 change periods. During this period, there was a significant decrease in transfer of rib fracture patients to higher level of care trauma centers (56% vs. 21%). The authors found that there was a similar LOS (length of stay) when comparing three or less rib fractures with those three or more rib fractured patients (3 [2–5] vs. 2 [1–4]) and mortality (0% vs. 2.3%). In addition, when performing a propensity match, no difference in age (median, 71 [60–81] vs. 73 [65–85], LOS, or mortality (1.7% vs. 0%).
The authors bring up an important point on the capabilities of level IV trauma centers vs transferring to level I/II trauma centers regarding ribs fractures. With that brings up the social and economic cost of dislocating patients from their home location, especially in rural areas where transportation and support systems can be limited and isolated to that specific region. This paper highlighted a significant decrease in the number of patients transferred once Pennsylvania standards changed starting in the year 2020. This paper showed no significant difference in LOS or mortality within the same median age and ISS group with a 1:1 propensity score. While we know transportation is sometimes warranted, i.e respiratory distress, displaced fractures, age, pneumo/hemo-thorax; perhaps rural/level IV trauma centers do have the safe capabilities of caring for these patients. Interestingly, they found level IV admitted more bilateral rib fractures than level I/II. While the paper did mention Western Trauma association 2017 recommendation for ICU admission, it did not mention the level of care/unit patients in their study. Depending on the level of care (medical floor, intermediate/step down, ICU) these patients were placed into, which can be resource limited and/or not available to some centers. Beyond this paper, what would be the “new” threshold of number of fractures level IV centers should transfer? This paper appropriately brings up that majority of uncomplicated rib fractures do not require higher level of care and should be triaged appropriately before transferring ultimately saving resources and dislocation burdens on patients.
Transferring patients to higher levels of care can be costly from both an economic standpoint as well as resource utilization in rural hospitals. Recently attention has been brought to non-therapeutic trauma transfers (NTT), resulting in significant resource use with no intervention provided to the patient at the receiving center. There are two main categories of NTT, Over-triage which results in transfer to a higher level of care only to be discharged from the emergency department, or Futile Trauma Transfers (FTT), in which the patient is transferred but dies or discharge to hospice within 48 hours without any intervention. Folette et al. found the average cost of FTT to be $56,396 but this does not include the added system burden of occupying transportation services, a tertiary care hospital bed, as well as the financial and emotional cost to families who may have significant distances to travel and coordinate. The authors sought to identify how often goals of care discussions occurred between the referring and accepting physicians in patients who were potentially FTT.
The authors retrospectively reviewed FTT to their level 1 trauma center between 2018 and 2022. FTT for this study included patients that died or were discharged to hospice within 48 hours without any intervention. They included patients who underwent confirmatory imaging that could have been completed at the referring hospital but was not, as well as patients who were brought immediately to the operating room but were found to have non-survivable injuries and either died or were converted to comfort measures during the case or immediately following. 80 patients met all inclusion criteria, of which 6 were pediatric patients, with the mean age being 70 years. All 80 transfer phone calls made between the referring ED physician and the accepting ED physician were reviewed for goals of care discussion. 52% of patients had TBIs, 23% were poly-trauma followed by less common indications. Code status was discussed in only 20% of cases, and in-depth goals of care discussion only occurred 10% of the time.
The expanded criteria was used to attempt to capture more patients who had increased risk of mortality when a goals of care discussion would be appropriate. Increased age was the only factor significantly associated with likelihood of discussion. 87% of the patients who did have these conversations had significant known co-morbidities including heart disease and metastatic cancer. Due to the nature of the study, it excludes all patients with whom a goals of care discussion resulted in declining transfer, so this may not reflect the frequency of these appropriate discussions.
The findings highlight a potential moment to target for quality improvement. The authors noted certain providers more often inquired about goals of care and code status than others, reflecting practice behaviors. This critical conversation between providers allows for a moment of pause and discussion in the course of what is often a rapidly evolving clinical scenario in centers who may rarely experience significant traumatic injuries, to ensure that the right thing is being done on behalf of the patient and the family.
The authors also found a potential focus for improvement by including neurosurgical specialists in the review of transfer and conversation, as 8 of 42 patients transferred for neurosurgery were deemed to have non survivable injuries based on neurological exam and imaging obtained at the referring hospital when interpreted by a neurosurgeon.
This article brings attention to a moment in time that could dramatically impact the family of these patients, as well as the medical system, with hope to change the thought processes and habits of providers. They also mention potential areas of research including development and validation of predictive tools to assist providers in these decisions. Most succinctly their paper brings into question the “never say no to a transfer” mantra, and begins to explore when it may be appropriate to ask “How can we support you in caring for your patient closer to home?”.
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