International Emergency Nursing 51 (2020) 100880

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International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Emergency trauma care in rural and remote settings: Challenges and patient T
outcomes
Janita M. Morgana,d, Pauline Callejaa,b,c,⁎
a
School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia
b
School of Nursing Midwifery & Social Sciences, CQUniversity, Level 3 Cairns Square, Corner Abbott and Shields Street, Cairns 4870, QLD, Australia
c
Retrieval Services Queensland, Department of Health, 125 Kedron Park Road, Kedron 4031, QLD, Australia
d
Gympie Hospital, Queensland Health, 12 Henry Street, Gympie 4570, QLD, Australia

ARTICLE INFO ABSTRACT

Keywords: Introduction: Trauma is a global public health concern, with higher mortality rates acknowledged in rural and
Trauma remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore
Rural and Remote vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve
Patient Outcomes mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant
impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary
objective of this integrative literature review was to examine the challenges associated with providing emer-
gency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective
was to explore strategies to improve trauma patient outcomes.
Methods: An integrative review approach was used to inform the methods of this study. A systematic search of
databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other
search methods included hand searching journal references.
Results: 2157 articles were identified for screening and 87 additional papers were located by hand searching. Of
these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique
challenges in the provision of emergency trauma care such as large distances, delays transferring patients to
definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors,
weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural
and remote populations often experience higher mortality rates in comparison to urban populations although
this may be different for specific mechanisms of injury or population subsets. While an increased risk of death
was associated with an increase in remoteness, research also found it costs substantially less to provide care to
rural patients in their rural environment than their urban counterparts. Other factors found to influence mor-
tality rates were severity of injury and differences in characteristics between rural and urban populations.
Trauma systems vary around the world and must address local issues that may be affected by distance, geo-
graphy, seasonal population variations, specific population risk factors, trauma network operationalisation,
referral and retrieval and involvement of hospitals and services which have no trauma designation.
Conclusions: The challenges acknowledged for rural and remote trauma patients may be lessened and mortality
rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma
systems that are responsive to local needs and resources. Additional research to determine which of these
challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce
existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as
well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve
this.

1. Introduction [1]. In Australia alone, 12,000 deaths each year result from trauma,
comprising 8% of all deaths [2]. Research confirms that patients in
Trauma remains one of the leading causes of mortality worldwide rural and remote areas experience higher mortality rates than those in

⁎
Corresponding author at: 2/60 Harbour Drive, Trinity Park, 4879, QLD, Australia.
E-mail addresses: Janita.Morgan@health.qld.gov.au (J.M. Morgan), p.calleja@cqu.edu.au (P. Calleja).

https://doi.org/10.1016/j.ienj.2020.100880
Received 4 October 2019; Received in revised form 16 April 2020; Accepted 7 May 2020
1755-599X/ Crown Copyright © 2020 Published by Elsevier Ltd. All rights reserved.
J.M. Morgan and P. Calleja International Emergency Nursing 51 (2020) 100880

Table 1
Search terms and results by database.
Search terms CINAHL Medline Embase Proquest Scopus Science direct

major Trauma AND Rural areas or communities 26 30 27 433 30 193

major trauma AND remote area or isolated community or rural community 23 12 0 121 4 73
major trauma AND Provincial 8 13 27 320 14 96
major trauma AND Isolated communities 52 12 0 4 0 0
Major Injur* AND Rural areas or communities 1 5 7 226 9 114
Major Injur* AND remote area or isolated community or rural community 1 1 0 45 1 24
Major Injur* AND Provincial 1 3 5 140 4 45
Major Injur* AND Isolated communities 0 0 0 3 0 4
112 76 66 1292 62 549

urban areas [3–6]. It is therefore imperative to improve outcomes for imperative to identify strategies at all intersections of the care con-
rural trauma patients, especially considering the health disparities that tinuum that may improve patient outcomes and ease the financial
already exist between rural and urban populations [3,7]. In response to burden of trauma.
such high mortality rates, trauma systems have been developed which
improve health outcomes by providing specialty care to trauma patients
2. Methods
regardless of their injury location [8,9]. Trauma systems aim to get the
right patient to the right place at the right time and include hospitals
The purpose of this study was to conduct an integrative literature
with differing levels of care provision and resources [10]. An integral
review with a narrative approach to analysis. The following research
component of trauma systems is the level one trauma centre or major
questions were used to guide this review.
trauma centre (MTC), which provides definitive care, access, required
resources and specialist services required to treat major trauma [8]. In
1. What are the challenges associated with providing emergency
comparison, non-trauma centres provide initial assessment, stabilisa-
trauma care for major trauma (ISS > 15) to rural and remote po-
tion, resuscitation, and identification of patients who require transfer to
pulations?
a trauma centre[8]. However, contention remains as to whether direct
2. How do these challenges influence patient outcomes?
transfer from injury scene to trauma centre is always an achievable
3. What strategies may improve patient outcomes from trauma in rural
option for rural trauma patients, as distance and remoteness often
and remote populations?
prohibits this. In Australia, not all trauma systems are created equally.
For example, the three biggest states of Western Australia, Queensland
From the results of the literature review, recommendations were
and Northern Territory make up over 70% of Australia’s total area, 2
made for future practice and opportunities for further research identi-
527 013 km2, 1 729 742 km2, and 1 347 791 km2 respectively [11]. The
fied.
challenges associated with ensuring patients from these areas receive
A systematic search of databases including CINAHL, Medline,
the specialist care they require at a trauma centre are far more complex
EmBase, Proquest, Scopus, and Science Direct was undertaken. The
than for the smaller Australian states such as New South Wales (801
search terms and results can be seen in Table 1.
150 km2) and Victoria (227 444 km2) [11], whose distances are less and
Inclusion criteria: primary research papers published between 01/
trauma systems are well established. Access to health services is often
01/2008 and 01/03/2020; peer reviewed articles; and research con-
limited in rural and remote communities, with increasing remoteness
taining information on trauma in rural or remote settings relating
directly associated with a reduction in access to services [12–14].
specifically to associated challenges, patient outcomes and strategies
Adding to these challenges are the financial, social and emotional im-
aimed at improving these.
plications for patients in rural areas when they are required to leave
Exclusion criteria: discussion papers, studies focused on me-
their hometown and travel long distances for definitive care. The fi-
tropolitan retrieval services, articles not written in English and those
nancial burden from trauma on both rural health services and MTCs is
which did not include full text due to resources available to the authors.
another area of concern [15], and highlights the significance of cor-
An integrative review framework by Whittemore and Knafl [17] was
rectly identifying which patients benefit from transfer to a MTC and
utilised to ensure this review was conducted rigorously and to reduce
which can be safely cared for in non-trauma centres. While the im-
bias. This process included clear identification of the problem and
portance of trauma systems in reducing mortality have been well es-
purpose of the review, a comprehensive search strategy as outlined in
tablished [16], difficulties in attaining definitive care at MTCs in a
the methods section of this review, assessment of methodological
timely manner requires further attention. Anecdotal feedback (authors’
quality of the research reviewed, analysis of extracted data including
experience and reported to the author from rural and remote clinical
identification of themes and synthesis of evidence, and finally pre-
staff) identifies multiple challenges associated with achieving this.
sentation of results and acknowledgement of implications for practice
Challenges include receiving hospitals requesting medical imaging
and research [17].
prior to transfer, then the consequential delays awaiting medical ima-
ging results. Added to this the referral process is drawn out, requiring
multiple phone calls from treating clinicians which removes them from 3. Results
time spent performing patient care. Other delays include ambulance or
retrieval services delays due to assets not being available. Increased Using the search terms previously described, 2157 papers were
stress is experienced when nurses are required to go on escorts, leaving identified, and 87 additional papers were located by hand searching
unsafe staffing levels in the rural emergency department, and finally of reference lists. Refer to Fig. 1: PRISMA Flow Diagram [18] for details of
having critical trauma patients delayed in a hospital which cannot search, and reasons for exclusion at full text stage.
provide definitive treatment. These challenges may not be fully un- Of the 49 studies, two were qualitative, 42 were quantitative and
derstood by clinicians from MTCs, who experience their own challenges five were mixed methods papers. The selected studies included 19 from
such as limited bed capacity that rural clinicians do not typically en- USA, eight from Canada and Australia, three from Turkey, two each
counter. Due to high mortality rates for rural trauma patients it is from Scotland, Germany and New Zealand and one each from Italy,
South Africa, Norway, India, Finland, and Hong Kong. Findings from

2
J.M. Morgan and P. Calleja
Fig. 1. PRISMA 2009 Flow Diagram [11].
the included articles were collated, critiqued and analysed using a
framework outlined by Whittemore and Knafl[17] (see Supplementary
Table S1 for Characteristics of included articles). The article findings
were synthesised to produce a summary of information (see Table 2 for
Challenges, outcomes and strategies to improve rural trauma care).
3.1. Challenges
There were several challenges identified in providing effective
emergency care to rural trauma patients. Long distances resulting in
delays to both prehospital treatment[19–21] and transfer to definitive
care[19,22–27] were the most commonly identified challenges along
with referral processes as often difficult, convoluted or not clear
[27,28]. Remoteness is not easily defined across all studies, and dif-
ferent countries have different ways of describing this term. In Australia
the Accessibility/Remotes Index of Australia (ARIA + ) is used [29].
For example, the current index used is the ARIA + index. Where Re-
mote is 5.92 to < 10.53 which is a score derived from averaging scores
of 1 km2 grid based on the road distances to service towns of different
sizes. Remote areas are additionally described as very restricted ac-
cessibility to goods, services and opportunities for social interaction.
Outer Regional areas ARIA score > 2.4 to < 5.92 are described as
significantly restricted accessibility to good service and opportunities
for social interaction [29].
One study in Western Australia found an average delay of almost
one hour for prehospital treatment and an average of 11.6 h from time
of trauma to arrival at a MTC [19]. In one study distances of up to
3
International Emergency Nursing 51 (2020) 100880
2500 km occurred for transfer to definitive care at a MTC [25]. It was
acknowledged by other studies that patients with higher Injury Severity
Scores (ISS) requiring more treatment interventions were responsible
for lengthy delays, not rurality or distance [30,31]. Limited access to
services and resources in rural settings [13,14,20,31,32] highlights yet
another challenge for this population.
Other challenges acknowledged include difficulty accessing local
trauma services due to delays in discovering injured patients due to
injuries occurring in remote and difficult terrain, on uncharted/private
roads, on roads or areas that do not have any or much passing traffic,
limited phone service, geographical and climate challenges (such as
climate extremes- very hot or very cold temperatures), and a lack of
system coordination [14,33]. A qualitative study identified that for
rural physicians maintaining adequate skills due to limited exposure to
trauma, and treating speciality populations as challenges to providing
optimal care to rural patients [34]. These changes are often com-
pounded by the availability and skill level of prehospital providers
[27,33,34]. The study by Berg et al. [34] also identified poor commu-
nication with tertiary hospitals and a lack of understanding regarding
the limited resources available in rural settings as additional challenges.
While these qualitative studies [33,34] explored personal experiences
elicited from focus groups, they provided valuable insight into the is-
sues faced by rural clinicians.
3.2. Patient outcomes
Increased trauma mortality rates were evident in rural populations
J.M. Morgan and P. Calleja International Emergency Nursing 51 (2020) 100880

Table 2
Challenges, outcomes and strategies to improve rural trauma care.
Challenges • Delays to definitive treatment:
-Limitations to prehospital resources and clinician skill level
-Longer distances
-Delays in access
-Transfer times to trauma centres
• Education and skill maintenance for rural staff
• Limited resources in rural settings

Outcomes • Mortality rates for patients:

-Increased mortality and disability for rural patients
• Factors affecting mortality rates:
-Differences in patient characteristics between rural and urbanpopulations
-Higher ISS score resulted in poorer outcomes
• Majority of deaths occur prehospital
• Non-trauma centres can effectively treat trauma patients in some studies with no difference in mortality
• Access to specialised care:
-Trauma centres considered definitive care and best treatment option by some studies and not by others
• Development of inclusive trauma systems have resulted in a decrease in transfers to MTC
Strategies to improve • Telemedicine:
-Cost effective
-Results in improved patient outcomes
• Inclusive trauma systems beneficial in rural settings
• Trauma specific training for rural hospitals, such as ATLS and RTTDC, proven to improve patient outcomes

[35–38], with the majority of rural trauma deaths occurring prehospital
[21,33,36]. Research from Australia observed more than double the
risk of death in the rural study population [19], and found that the risk
of death increased with remoteness [25] and may be specifically related
to certain types of mechanism of injury as well [37,39,40]. More spe-
cifically, there was a 19% increased risk of death per hour for rural
trauma patients awaiting prehospital treatment [19], and an 87% in-
creased risk of death for every 1000 km distance to a MTC[25]. Rural
populations were also found to have worse functional outcomes at
hospital discharge than urban populations [41]. Interestingly, a study
by Dinh et al. [42] found mortality rates decreased for rural patients
over a five year period, but remained unchanged for urban patients.
Potential explanations for these findings were changes made to the
trauma system prior to commencement of the study, which focused on
improving referral networks and decreasing transfer times [42]. Addi-
tional research found rural patients in New South Wales, Australia had
shorter length of stay hospital admissions and were less likely to be
readmitted within 28 days compared to urban patients [43]. It also cost
substantially less to treat rural trauma patients than their urban coun-
terparts [43] and this is related to fewer interventions and imaging
being available to be carried out.
It remains contentious whether exclusive trauma systems, focusing
on treatment at a MTC, reduce mortality rates significantly when
compared to care provided in a comprehensive, inclusive trauma
system. One study argued that MTC care is associated with improved
mortality rates in comparison to non-trauma centres [44]. This study by
Garwe et al. [44] was a retrospective cohort study, lacking the rigour of
a Randomised Control Trial (RCT). However, while considered the gold
standard in research, a RCT would not be ethical or practical in this
setting and the study by Garwe et al. [44] certainly contributes to the
knowledge on this subject. Additionally, a strength of this research was
that it utilised propensity scores in at an attempt to minimise selection
bias resulting from heterogeneity of patient characteristics, clinical
status and availability of resources [44]. Yet another study found in-
creased mortality rates in non-trauma centres [45], however due to its
small sample size (n = 223) and consequential effect as a potential
confounder influencing results [45], this study design had limitations.
One study found designation of a level three trauma centre resulted in
significantly less transfers to a MTC without an associated increase in
mortality [46]. Several other studies argued that mortality rates are
similar between trauma and non-trauma centres [22,23,30,42,47], or
may be slightly better in level II trauma centres, especially where a
reduction in travel for local patients can be supported by local infra-
structure and services [48]. However, some of these studies had lim-
itations in their methodology, as Lipsky et al. [47] utilised data which
was 18 years old and hence not indicative of current injury patterns and
the research by Newgard et al. [23] was based on a secondary analysis
of another study conducted by the authors. Other research suggests that
rural non-trauma centres are an integral component of an inclusive
trauma system and that patients can safely receive treatment at these
hospitals before transfer to definitive care without an increase in
mortality [19,26,46,48,49] and that if all rural trauma patients were
sent only to MTC then the demand would overwhelm these resources
[48,50]. The research conducted by Fatovich et al. [19] was robust, and
although retrospective in nature, used techniques such as multiple
imputation and weighted analysis to eliminate selection bias and pro-
duce valid results. The study by Wild et al. [26] did not attempt to
reduce this selection bias, indicating limitations to study design.
It has also been acknowledged that factors other than level of hos-
pital result in higher mortality rates, such as higher Injury Severity
Scores (ISS) [22,30,34,45]. Higher Glasgow Coma Scale (GCS) score
[26,45], fewer required interventions to stabilise the patient, and vital
signs within normal limits were also deemed factors associated with
improved outcomes [26], suggesting that clinical factors may con-
tribute to patient outcomes as much as level of treatment facility. Other
studies point to other factors that may impact, specific to populations
such as deprivation level of the population, socioeconomic factors that
impact general health and wellbeing, burden of mental health issues,
local job role types (e.g. farming, fishing etc.) other comorbidities and
risky lifestyle factors (e.g. alcohol consumption, seatbelt or restraint
use, speed etc.) [13,14,21,38,51–54]. This seems a logical deduction, as
the more acutely unwell the patient, the more interventions required,
and therefore the more likely to have poor outcomes due to level of
injury. One study [26] acknowledges this issue about a cohort studied
in that their findings as discussed above were probably related to the
fact that more severely injured patients were likely to have died before
being able to be transferred to an MTC and therefore they would have
been excluded from this study.
Another finding from the included research was that patient char-
acteristics differed between rural and urban populations. In some stu-
dies urban patients had more severe Traumatic Brain Injury (TBI)
[22,26] and penetrating injuries [22] while in others rural patients had

4
J.M. Morgan and P. Calleja
higher frequency and more severe TBI [55,56]. In comparison, rural
patients experienced more injuries from blunt trauma [24,26,47], road
trauma [25,42,43], and falls [23,26,47]. Furthermore, rural patients
were also more likely to have more comorbidities [22,26] and this is
due to lower levels of education, preventative medicine, food variety,
lower socio economic factors, less access to healthy lifestyle support
activities and less social activities being available [14,57]. Trauma
patients, regardless whether rural or urban, were frequently male
[25,42,46,53,58]. However, some research found that rural patients
were more likely to be young (aged 16–24) [42], whereas other studies
found rural patients were more commonly female [23,26,47], and older
[22,23,26,47,55] with recommendations that age should be a trigger
for transfer to a higher level trauma care on its own [55], a similar
recommendation if the patient required pre-hospital intubation [59].
These findings suggest a wide variety in the presentation of rural
trauma patients and indicate they do not adhere to a specific stereotype
and this has been found in a number of studies [58]. These variances
observed due to heterogeneous cohorts may influence mortality rates
between rural and urban populations and consequently produce biased
results.
Interestingly, some studies found increased mortality rates for rural
patients at a MTC, compared to urban patients [35,54] and others had
higher rates of mortality for urban patients compared to rural patients
transferred there [40,60] or no difference at all [31,39]. While others
found higher mortality for rural patients treated at rural sites [61].
These results were potentially reflective of the critical status of patients
treated at MTCs and in some cases due to the acknowledged higher
mortality rates for rural patients [35,36] or the population subsets and
associated mechanisms of injury within urban or rural populations
[54,60]. Increased distance and travel time to definitive care for rural
cohorts were also likely contributors for this result [35]. Also, pre-
hospital deaths in rural areas were not included in these studies. This
remains a common problem with retrospective studies of this nature,
with the majority not including deaths on scene in rural areas or even
death upon arrival to hospitals due to lack of access to death registry
data [19,23,25,26,35,41,44,45]. Consequently, this selection bias can
influence results as mortality rates in rural areas may be higher than
previously thought. Other identified areas of bias within the literature
reviewed were small sample size [32,45], hence lacking internal va-
lidity. A sample size should be large enough to produce useable data
and true results [62]. Additionally, some research was conducted at a
single hospital site[22,26], resulting in a lack of external validity and
inability to generalise results outside of the original study [62]. One
study that did include mortality before emergency service arrival on
scene found that introduction of a trauma system, upskilling of staff and
other such improvements did nothing to impact on deaths that occurred
before help could arrive on scene [21], and logically only shorter re-
sponse times may impact this.
3.3. Strategies to improve
Telemedicine was identified as the most pertinent strategy in ef-
fectively managing rural trauma patients by increasing access to spe-
cialist services and resources [32]. Telemedicine was found to be a cost
efficient strategy due to a reduction in unnecessary transfers, and faster
transfer time to tertiary centres for necessary patients [32].
Strategies to reduce transfer time from injury scene to care are
discussed widely, however some studies show no difference in mortality
for ground vs air transport while others do [63,64]. However, this may
have other factors impacting outcomes such as different mechanisms
[31] and the inherent increased severity of injury such as those with
high velocity related injury.
Trauma certification and standardised triage and referral processes,
recruitment and retention of skilled staff, expansion of equipment and
approaches associated with a developed trauma system also contributed
towards improved patient outcomes and provided more educational
5
International Emergency Nursing 51 (2020) 100880
opportunities [20,21,27,28,34,60,65–68].Trauma training [27] and
training that is specific to particular cohorts (e.g. paediatric patients)
[20,56] and rural specific models of care empowered clinicians to safely
and effectively treat rural patients at non trauma centres [34,47].
However one study did find that the addition of more qualified staff was
not enough on its own to impact morbidity, this needed to be supported
by increased local infrastructure and other resources such as blood
bank, supporting personnel and access to imaging [49]. Prevention
programs aimed at specific risk factors in rural populations is a common
strategy suggested as well [58].
Trauma systems should be planned with the context of the local
populations, resources, cultural and societal influences taken into ac-
count [13,28,53,58] as some factors can be modified and others must
be taken into account as they are not modifiable (e.g. weather, distance
etc.) [67]. Trauma systems are complex and should reflect and include
stakeholders and data from all feed-in points, not just from designated
trauma centres [27,55,60].
4. Discussion
While research has established that higher trauma mortality rates
occur in rural populations [14,21,35,37,38,51,54,56,61,69,70], it re-
mains unclear which factors have the greatest effect on these poorer
outcomes. Although long distances resulting in delays to pre-hospital
treatment [19,38,71,72], and definitive care [8,19,22–26,70,73] are
common in rural settings and often unavoidable, there are other issues
which may also cause delays. Research has shown that utilising Heli-
copter Emergency Medical Services (HEMS) where appropriate and
available has been associated with improved mortality rates and de-
creased delays associated with distance [74], however unavoidable
delays may occur if retrieval services are not available when required
due to limited resources or an inability to operate due to bad weather,
and in many rural and remote settings, distances are too great to be
managed with HEMS [64]. While this study does not relate to fixed
wing capability retrieval services which can service longer distances in
remote areas, any retrieval service can still experience delays if assets
are all already tasked or are offline for maintenance or pilots having
reached flying hours limits. Conversely, other delays may be avoidable,
such as those caused by medical imaging in rural hospitals prior to
transfer to definitive care [8,67,75,76], especially considering repeat
imaging is often performed at tertiary hospitals [76–78]. It is essential
to get this balance right however, as medical imaging can be useful in
determining which patients can safely stay in rural hospitals and which
require transfer to a MTC [75,79]. Additionally, issues involving access
to definitive care such as difficulties with referrals and retrieval pro-
cesses often result in preventable delays [27], and further studies could
be conducted to see what factors improve referral and retrieval services
for efficiency. Limited resources and staffing levels[8,27,32] are also
challenges which impact on the ability of rural clinicians to provide
quality care to trauma patients and achieve comparable health out-
comes.
Prehospital care is also an area of concern in rural areas, with many
deaths occurring before arrival to hospital [4,5,21,33,36]. Limited re-
sources, adherence to protocols (due to a number of factors that vary
with local resourcing, education and applicability to context), a wide
variation in staffing skill, and delays in discovering injured patients
[8,65,68] all influence the quality of care provided by prehospital staff.
In some rural areas in Australia and USA, prehospital care is delivered
by volunteers who can only provide basic services [8,80]. A physician
staffed prehospital service has been found to be beneficial in im-
plementing time critical interventions in major trauma patients
[81,82], and may be one strategy to consider when encouraging pre-
hospital bypass protocols. Prehospital field guidelines and triage pro-
tocols have been developed in an effort to identify potential injury and
determine which patients would benefit from trauma centre care and
which can be initially safely cared for in rural hospitals [8,83]. The
J.M. Morgan and P. Calleja
term “golden hour” suggests that time is critical for trauma patients and
that patients experience better outcomes if they receive access to de-
finitive care within 60 min from sustaining injury and subsequently has
formed the justification for modern trauma systems and prehospital
processes [13,14,84–86]. However limited research was able to be
found which supports this theory [80,87], but many of the current
studies use 60 min as a threshold transfer time [13,14,38,66]. While
literature supports the direct transport of critical trauma patients from
injury scene to a MTC for definitive care [8,44,83], this concept has
limited applicability in rural settings as the need for stabilisation and
distance often prohibits this [8,87–90]. For example the Queensland
Ambulance Service (QAS) Clinical Practice Guidelines for Trauma/pre-
hospital trauma by-pass [91] provide clinical indicators for the direct
transfer of major trauma patients to a MTC if one is available within
45 min transport by road, and if not advise transfer to a Regional
Trauma Service (RTS) if available within 45 min [91]. Unfortunately,
due to the size of Queensland and the long distances between towns
outside of major cities, many patients are not even within transfer
distance of a RTS and instead therefore necessitate transfer to the
nearest local hospital. So while direct transfer to a trauma centre is
recommended practice and may be achievable in smaller trauma sys-
tems in Australia such as NSW or Victoria, it is simply not possible to
safely achieve this in areas of rural Queensland without medical in-
tervention and stabilisation at a rural hospital first.
The subject of trauma centre care remains a contentious issue. While
clinicians and scholars from MTCs may feel current trauma systems are
inclusive and functioning well, rural clinicians faced with experiencing
lengthy delays for transfer and acknowledged challenges may disagree.
Arguments have been made for direct admission to a trauma centre due
to improved patient outcomes [44,92,93], and arguments have been
made that the majority of trauma care can be effectively provided at
non-trauma centres with comparable mortality rates for many patients
[22,23,26,30,47,94–96]. These conflicting results raise questions re-
garding the sustainability of trauma centres, or systems that require
direct admission to a trauma centre that have large rural remote
catchment areas, as it costs significantly more to provide treatment
there [8,32]. Further research to resolve this argument would be ad-
vantageous. Trauma systems are and should be reflective of their local
context, however this creates a level of complexity that makes it diffi-
cult to compare trauma centre outcomes, and impose rigid guidelines
on how trauma systems should look. Local needs, resources, number of
support services, and governing structures all should plan what is
needed with a wide variety of stakeholders to meet the local needs
[13,28,53,58] Research has found a reduction in mortality following
the development of state wide inclusive trauma systems [97,98]. It has
been advocated that the optimal trauma system promotes treatment of
mild injuries at local hospitals and transfer of severely injured patients
needing specialist services to MTCs [65,68,79].
Emphasis on early identification and transfer of patients requiring
trauma centre care is considered best practice [8,99]. This is important
because unnecessary transfer of stable patients to trauma centres result
in increased costs and wasted resources [100,101]. However, it is
equally as important to ensure that trauma patients are not under
triaged, which occurs when severely injured trauma patients (ISS > 15)
who require specialty services are not transferred from non-trauma
centres to MTCs for definitive care and are associated with increased
mortality[102]. In contrast, secondary over triage has been defined as
the unnecessary transfer of trauma patients with minor injuries
(ISS < 15), who often do not require surgical intervention and are
discharged from MTC within 48 h [79,103]. While not the focus of this
literature review, the issue of secondary over triage is certainly perti-
nent and impacts on the ability of MTCs to effectively provide care.
Secondary over triage is a reflection of the efficiency of a trauma system
[103,104]. This phenomenon often occurs due to inadequate resources
at rural hospitals [79,100,103]. Rates of secondary over triage to MTCs
vary from conservative amounts such as 9.8% [79] and 12.2% [103], to
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International Emergency Nursing 51 (2020) 100880
larger volumes of 26% [100], 39% [104], and 53% [105]. While these
numbers may seem alarming, research has demonstrated the majority
of all trauma patients (both transfers and patients directly admitted
from scene) received at a MTC were minor, and that transferred pa-
tients were more severely injured than directly admitted patients [104].
Secondary over triage should be limited to reduce costs and decrease
burden on MTCs. It is estimated to significantly cost MTCs, at a rate of
$USD $67,512 per patient [101]. Suggestions for how to achieve a safe
reduction in secondary over triage include maintenance of well-estab-
lished transfer guidelines from both prehospital providers and rural
hospitals to reduce triage errors [103,104] and use of telemedicine to
assess patients before transfer is arranged [100,103]. Non-trauma
centres are a cost effective part of inclusive trauma systems and can
provide care for the majority of patients who do not require definitive
care [106], whereas MTCs are beneficial for severely injured trauma
patients. A balance needs to be found to determine which patients can
be safely treated at non trauma centres and which benefit most from
transfer to MTC to ensure cost and resource effectiveness of trauma
systems.
Access to specialist services is often limited in rural areas
[32,34,80], due to smaller populations and consequent less demand for
these services. The use of telemedicine is therefore beneficial as it
provides improved access to medical services and educational oppor-
tunities for staff that are otherwise not available [107,108].Tele-
medicine is a cost effective initiative that improves the quality of care
provided to rural patients [32,109–111], decreases transfer times to
trauma centres [32,110,112], and also promotes collaboration amongst
health professionals [110]. The future of telemedicine is innovative
with recommendations for use in surgery and medical imaging [32] to
improve patient outcomes.
Education and training courses have been designed specifically to
improve patient care and to assist clinicians in early identification of
patients requiring transfer to trauma centres, one example is the Rural
Trauma Team Development Course (RTTDC) [8,99]. Research fol-
lowing the introduction of RTTDC found decreased length of stay and
earlier transfer acceptance times in rural hospitals [67,113]. Advanced
Trauma Life Support (ATLS) training has also been found to improve
patient outcomes [8], although lack of adherence to guidelines in rural
areas continues to be an issue [68] with wide variation in management
evident across a number of studies. Education and training in rural
areas enables clinicians to confidently provide initial resuscitation, as
well as encouraging collaboration and effective communication with
trauma centres [8,99]. The growth and increased utilisation of tele-
medicine, ongoing education and the continuing development of in-
clusive trauma systems are all strategies that assist to improve trauma
outcomes in rural populations.
5. Recommendations
Further research to determine which of these identified challenges
has the most impact on health outcomes will be a positive step in re-
ducing existing disparities between rural and urban populations, if this
is then taken into account when planning trauma care and resources.
Considering the evidence of equivocal mortality rates for most patients
in trauma and non-trauma centres, the current focus on exclusive
trauma systems should be redirected to embrace and expand inclusive
trauma systems which complement and support these facilities. More
research is required on the rural and remote context of inclusive trauma
systems as metropolitan clinicians do not fully understand the struggles
faced by rural clinicians impeded by distance and societal differences.
Additional research into strategies to improve and standardise pre-
hospital care is also required. ISS, the tool used to predict trauma se-
verity is calculated retrospectively and does not assist prehospital
providers with triage decisions nor is it a great predictor of mortality.
More research into triage decision making and processes for prehospital
providers is required. Encouragement of the use and growth of
J.M. Morgan and P. Calleja
telemedicine in rural settings, including delivery of education to rural
clinicians, would also be beneficial. Increasing opportunities for trauma
training could benefit both patients and staff. Research which is in-
clusive of all trauma related deaths from both rural and urban areas
would be valuable and reduce study bias. This may be achieved by
using data from death registries in conjunction with trauma registries
while undertaking research. Such additional information may highlight
that a focus on injury prevention may be beneficial in rural populations.
The majority of the studies reviewed focused on outcomes for trauma
patients of an ISS > 15 (considered the definition of major trauma),
however these studies do not take into consideration the large number
of patients who require similar treatment and interventions with
ISS < 15 [114]. Studies into prevention of trauma need to be focused
particularly in rural communities and take into account the demo-
graphics and socio-economic factors that impact on health and risk-
taking behaviours. Local planning for healthcare providers should in-
clude specific knowledge of local trauma related injury foci and what
this means for education, referral and retrieval processes (e.g. different
education and resourcing would be needed in areas that have high
motor vehicle trauma compared to high suicide behaviours).
6. Limitations
A limitation of this review is that a single author extracted data from
most research articles, a second reviewer was only able to extract data
from selected papers due to resources. This review would have been
made stronger with a second reviewer separately extracting data and
comparing results for all papers. Additionally, having resources neces-
sary to access research papers not written in English may have broa-
dened the scope of this review. Limited current research regarding
trauma systems in larger rural areas such as Queensland, Australia was
also a limitation of this review.
7. Conclusion
Providing trauma care in rural and remote settings is made difficult
by the challenges of distance, limitations to resources and staffing, lack
of access to definitive care at trauma centres and prehospital care
concerns. These challenges all contribute towards the acknowledged
higher mortality rates in rural and remote populations. Strategies aimed
at improving outcomes for rural patients such as telemedicine, trauma
training, education and the development of inclusive trauma systems
will continue to assist in reducing mortality rates and improving patient
outcomes.
Disclosures
The authors have no disclosures to make and have not received
funding from any sources.
Authorship
The authorship of this article was as follows. JM and PC conceived
and designed the study. JM conducted data extraction and analysis,
supervised by PC. JM prepared the manuscript. JM and PC edited and
approved the manuscript.
Acknowledgement
Jessica Schults, Griffith University for review and feedback on
manuscript
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ienj.2020.100880.
7
International Emergency Nursing 51 (2020) 100880
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