By Tara Bannow

The Bulletin

Far fewer trauma patients in rural Oregon and Washington who needed a high level of care received it compared with those in urban areas, a new Oregon Health & Science University study found.

Dr. Craig Newgard, an emergency medicine professor at OHSU and the study’s lead author, said he hopes his research, published in the Journal of the American Medical Association Surgery, clears up the widely held misconception that small hospitals are transferring too many patients to larger ones, even when it’s not necessary. He thinks the opposite is true.

“We should probably be transferring more patients,” he said, “and we should probably be trying to zero in on the right patients to transfer and identifying them early.”

Although the study did not include data from Deschutes, Crook or Jefferson counties, it could have important implications for Central Oregon, where emergency responders and hospitals are often faced with tough decisions about where to send patients.

It takes responders roughly 45 minutes to bring a patient from Madras to Bend, said Mike Lepin, assistant chief of the Jefferson County Emergency Medical Services, which is based in Madras. That raises the question of whether to first stabilize them at the Madras hospital before bringing them to Bend.

“The one factor we have no control over is time,” Lepin said.

Of the 53,500 injured patients in the study transported by EMS personnel, 29.4 percent who needed critical care were brought to a major trauma center, defined as a level 1 or level 2 trauma hospital. In urban areas, that was 88.7 percent. After transfers from the initial, smaller hospitals were factored in, about 40 percent of rural patients who needed critical care were ultimately brought to major trauma centers versus 88.7 percent of urban patients.

The study included all emergency medical responses for injured children and adults in seven counties — five urban and two rural — in 2011. Counties were considered urban if they were within a 30-minute drive of a level 1 or level 2 trauma hospital.

St. Charles Bend is a level 2 trauma hospital. There are two level 1 hospitals in Oregon: OHSU and Legacy Emanuel Medical Center, both in Portland. St. Charles Redmond is a level 3 hospital, and Madras and Prineville offer the lowest level of trauma care.

Transfers not happening

It’s not that EMS personnel in rural areas do a worse job of identifying who needs critical care compared with their urban counterparts, it’s just that the hospitals are much further away, Newgard said.

Most EMS personnel bring seriously injured patients to a small hospital to be stabilized under the assumption that the hospital will then send those patients to a major trauma center, he said. But as it turns out, he said, the latter isn’t happening in the majority of cases.

Lepin, with Jefferson County EMS, said his team sometimes takes seriously injured patients to the nearest hospital, whether it’s Madras or Redmond, so doctors can stabilize their condition as quickly as possible. After that, he said they’re transferred to Bend or Portland.

In other cases, Lepin takes seriously injured patients straight to Bend, especially if the weather is good and they can use one of the region’s two medical helicopters.

Once patients arrive at St. Charles hospitals, several important factors could prevent them from being transferred to Bend or Portland: either their condition or the weather won’t allow it or there’s no intensive care beds available at the other hospitals.

Eric Blankenship, St. Charles’ trauma program manager, said weather tends to be the biggest barrier. Icy roads can prevent driving patients and snowstorms or fog can prevent flying them.

Hospitals are obligated to make sure a patient is in good enough shape — they’re breathing and their bleeding is stabilized — to travel to Bend or Portland before they’re sent there, said Karen Ellis, director of patient care services for St. Charles Prineville.

“It could be less safe for the patient and actually harmful if they were airlifted in an unstable condition,” she said.

Lack of beds a factor

Hospitals statewide, St. Charles included, are also dealing with a serious shortage of ICU beds, a problem that can prevent patients from being brought to Bend, Ellis said. When EMS personnel bring a patient to a hospital who then needs to be transferred, the hospital staff must determine which hospital has an open bed.

If there’s nothing in Bend, that means they’ll go to Portland, she said.

“We transfer to OHSU, for example, quite a bit,” Ellis said.

In one case about a year ago, St. Charles sent a patient to Boise, Idaho, because there were no ICU beds in Oregon or Washington, she said.

Before sending patients to Portland, St. Charles’ doctors must make sure they’re well enough to make the trip, Ellis said.

“It’s a risk without a doubt, but I’m pretty confident in the folks that do the job,” she said.

Newgard said he hopes his study encourages hospitals to determine what issues — whether they’re logistical or due to poor relationships between hospitals — are preventing them from making transfers.

The study doesn’t reveal why patients were not transferred, but Newgard said it can be conditions beyond the hospital’s control. Sometimes patients themselves may not want to leave their community to go to the urban area, he said.

If there’s a chance patients won’t survive their injuries, providers might also fret over taking them away from their families, Blankenship said.

“If they are gravely injured, they may not be alive when the family members drive to Portland to meet up with them,” he said.

It could also be that smaller hospitals can be criticized for transferring patients to larger hospitals if the larger ones deem the transfer unnecessary, Newgard said.

Ellis said she’s not heard of St. Charles getting any pushback from OHSU or Legacy Emanuel for sending patients there.

“If we do, I’m not aware of it,” she said.

No mortality difference

Contrary to several previous studies, this one did not identify a difference in overall mortality between the urban and rural patients. Previous research has determined people in rural areas are more likely to die from injuries.

Those studies, however, are based on data that’s more than two decades old, Newgard said. In any case, the lack of difference his team identified in its study could have been due to the small rural sample size. Only two rural counties, Josephine in Oregon and Skamania in Washington, were included.

Another possibility Newgard suggested is that the mortality rate truly is not dramatically different between urban and rural areas.

“It was interesting that we weren’t able to demonstrate a difference,” he said, “but what that means and whether that’s true for all rural areas in sort of a new era, we just don’t know the answer to that.”

Among patients who ultimately died from their injuries, the study found 90 percent of rural patients died within 24 hours of being injured, compared with 64 percent of urban patients. Newgard said that’s likely a factor of travel time: It took EMS longer to get to them and bring them to the hospital.

— Reporter: 541-383-0304,

tbannow@bendbulletin.com

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