Profile of trauma mortality and trauma care resources at rural emergency departments and urban trauma centres in Quebec: a population-based, retrospective cohort study

Abstract

ObjectivesAs Canada’s second largest province, the geography of Quebec poses unique challenges for trauma management. Our primary objective was to compare mortality rates between trauma patients treated at rural emergency departments (EDs) and urban trauma centres in Quebec. As a secondary objective, we compared the availability of trauma care resources and services between these two settings.DesignRetrospective cohort study.Setting26 rural EDs and 33 level 1 and 2 urban trauma centres in Quebec, Canada.Participants79 957 trauma cases collected from Quebec’s trauma registry.Primary and secondary outcome measuresOur primary outcome measure was mortality (prehospital, ED, in-hospital). Secondary outcome measures were the availability of trauma-related services and staff specialties at rural and urban facilities. Multivariable generalised linear mixed models were used to determine the relationship between the primary facility and mortality.ResultsOverall, 7215 (9.0%) trauma patients were treated in a rural ED and 72 742 (91.0%) received treatment at an urban centre. Mortality rates were higher in rural EDs compared with urban trauma centres (13.3% vs 7.9%, p<0.001). After controlling for available potential confounders, the odds of prehospital or ED mortality were over three times greater for patients treated in a rural ED (OR 3.44, 95% CI 1.88 to 6.28). Trauma care setting (rural vs urban) was not associated with in-hospital mortality. Nearly all of the specialised services evaluated were more present at urban trauma centres.ConclusionsTrauma patients treated in rural EDs had a higher mortality rate and were more likely to die prehospital or in the ED compared with patients treated at an urban trauma centre. Our results were limited by a lack of accurate prehospital times in the trauma registry.

Canadian in-hospital mortality for patients with emergency-sensitive conditions: a retrospective cohort study

“…(22) This finding echoes previous reports that highlighted significant disparities in access to high-quality emergency care in Canadian rural communities. (23,24) In the same way it was done for trauma care across the country, Canadian decision-and policy-makers could use the ED-HSMR to trigger in-depth performance assessment to help identify opportunities for improving emergency care structures and processes to improve patient outcomes. As worrisome as they are, wait times henceforth do not appear to be the only important risk factor impacting outcomes of ED patients with emergency sensitive conditions.…”

A Canadian Rural Living Lab Hospital: Implementing solutions for improving rural emergency care

“…Our recent trauma study showed that mortality in rural settings was 3.4 times higher than in urban environments and that 50% of trauma deaths occurred in the pre-hospital setting. 11 Locating victims and preparing timely trauma response and transport is critical. Yet in rural and remote areas it can be difficult to locate victims and deliver the necessary medical equipment (defibrillators and blood products) in a timely manner.…”

“…[7][8][9] Our studies have shown that Canadian patients treated in rural hospitals are 20% more likely to die from a stroke than patients treated in urban hospitals and that rural Quebec trauma patients had pre-hospital and ED mortality rates 3.4 times higher than their urban counterparts. 10,11 We have also previously undertaken a number of research projects aimed at integrating scientific knowledge about rural EDs with the experiential knowledge of various stakeholders. [12][13][14] Among them, the Rural Emergency Care 360 project aimed to engage rural community members, healthcare providers, managers and policymakers in identifying needs, and imagining and taking ownership of initiatives likely to improve care and services.…”

Improving delivery of care in rural emergency departments: a qualitative pilot study mobilizing health professionals, decision-makers and citizens in Baie-Saint-Paul and the Magdalen Islands, Québec, Canada

“…We conducted a multiple case study to explore challenges and solutions for improving rural EDsan appropriate design for considering multiple stakeholders' perspectives within their context [17]. The province of Quebec has 26 EDs that meet the definition of "rural" used in our previous work, which is based on the following criteria (1) located in cities with a population of less than 15,000 (2016 census data); (2) 24/7 physician coverage; (3) hospital with patient admission capability; and (4) located more than 50 min of ground transport from a level 1 or 2 trauma centre [18]. Of Québec's 26 rural EDs, the research team selected, by convenience, two contrasting cases: Baie-Saint-Paul Hospital and Archipel Hospital at Cap-aux-Meules in the Magdalen Islands (see Map 1).…”