Geography of the Underserved: The Contribution of Rural Non-trauma Hospitals to Trauma Care

OBJECTIVE: To determine the proportion and characteristics of injured rural residents treated at urban trauma centers (TCs), urban non-trauma centers (NTCs), rural TCs, and rural NTCs.

SUMMARY BACKGROUND DATA: Timely treatment at a designated TC improves outcomes for patients with serious injuries, but rural residents have limited access to designated TCs. Rural NTCs may constitute an under-recognized source of TC.

METHODS: We used the National Emergency Department Sample to conduct a retrospective, pooled cross-sectional study of ED visits among rural residents with injury severity score (ISS) ≥ 9 (indicating at least moderate injury). Hospitals were designated as TC or NTC and as rural or urban. We compared management, disposition, and outcomes among hospital types.

RESULTS: Of 748,587 injured rural residents from 2016 to 2020, 384,113 (51.3%) were treated in rural NTCs, 232,845 (31.1%) in urban TCs, 116,493 (15.6%) in urban NTCs, and 15,137 (2.0%) in rural TCs. Injuries treated at rural NTCs were moderate in severity (ISS: 9-15) in 76.6% of visits, severe (ISS: 16-25) in 15.7%, and very severe (ISS: >25) in 1.1%. Urban TCs saw the highest proportion of very severe injuries (17.3%). Rural NTCs managed 77.5% of visits definitively, discharging 72.8%. They transferred 21.9% of patients. The length of stay was the longest, and hospital charges were highest for patients treated in urban TCs, which also performed the most procedures. Rural NTCs had the shortest length of stay and lowest mean charges.

CONCLUSIONS: Rural NTCs provided initial care for more than half of injured rural residents, including 2 in 5 of those with the most severe injuries, and managed more than 3 in 4 definitively. These hospitals may be an under-recognized component of the US trauma system.