title: Trauma care at rural level III trauma centers in a state trauma system.
abstract: BACKGROUND
  Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care.
  
  
  METHODS
  During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail.
  
  
  RESULTS
  A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5.
  
  
  CONCLUSIONS
  Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.
authors.affiliation: Missouri Committee on Trauma and the Department of Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA. thelling@conemaugh.org
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Helling
mesh_terms: D006780:Hospitals, Rural / Q000458:organization & administration*; D006801:Humans; D008923:Missouri / Q000453:epidemiology; D012041:Regional Medical Programs / Q000458:organization & administration*; D012189:Retrospective Studies; D012424:Rural Population; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000628:therapy