Geographic isolation in rural areas results in the doctor's office or rural community hospital being the de facto primary care provider. Primary transport to a trauma center is not a viable option in most rural settings in the United States.
Such a facility may or may not have a physician immediately available. The initial patient encounter may be the responsibility of a nurse. Early assessment and resuscitation place a heavier burden on rural emergency nurses than their urban counterparts. The nurse may await the arrival of a physician from outside the hospital. The responding physician usually is a primary care provider and infrequently encounters the multiple injured patient. The level IV center is expected to provide advanced trauma life support prior to the patient's transfer to a higher level trauma center. The American College of Surgeons (ACS) notes that the level IV facility is not meant to provide a downgraded option for a less than fully committed level III hospital. Resources for the Optimal Care of the Injured Patient: 1993. Committee on Trauma, American College of Surgeons.
Dr. Steven Shackford notes that the elimination of marginal hospitals in rural areas with no other hospitals would likely be detrimental to trauma patient outcome. Recognizing this potential of reducing trauma services in rural settings, the most recent revision of the optimal resources document allows for local flexibility in the interpretation of some of the criteria, provided that protocol modifications are monitored carefully by a quality improvement process. The current document is therefore more inclusive, allowing greater institutional participation and recognizing the role of the rural community hospital in quality trauma patient care. Surg Clin North Am. 1995; 75: 149.
The probability of death caused by a traumatic injury is higher in rural areas. Two-thirds of all motor vehicle related deaths occur in the rural setting. The majority of rural traumatic injuries are from motor vehicle accidents and from falls. Arch Surg. 1994; 129: 800.
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