The proportion of PCD call-outs to severe trauma incidents was higher in rural than in urban areas. This was shown directly in the variable centrality group, but also indirectly in the variables regional Health Authority area and EMCC area. Compared to the most urban (centrality group one), there were significantly higher proportions of PCD call-outs to severe trauma incidents in more rural municipalities (centrality groups three, four, five and six). In the regional Health Authority areas West and Central, PCDs had significantly higher proportions of call-outs compared to PCDs in the most urban area South-East. We observed a large variation both in proportions of PCD call-outs to severe trauma incidents and call-out rates per 100,000 inhabitants per year across the 16 EMCC areas.
Several studies comparing prehospital trauma care in urban and rural areas have found higher mortality rates after trauma, fewer emergency medical health personnel per inhabitant, and longer distances from the incident scene to the trauma hospital in rural areas [6,7,8, 19,20,21,22,23,24,25]. Some studies also observed that injuries were more severe in rural than in urban areas [19, 20, 22]. It is likely that the same challenges apply to rural areas in Norway. This study is unique as it analysed factors affecting PCD call-outs to severe trauma based on national data. This provided insight into the overall frequency of call-outs as well as rural-urban differences.
Due to fewer emergency medical health personnel and longer transport distances to trauma hospitals requiring continuous assessment and urgent measures, PCDs in rural areas have a more important role in prehospital trauma care compared to urban areas [12, 26]. PCDs working in rural areas are aware of the limited availability of medical resources, including ambulances and the HEMS. This may partly explain why PCDs in rural areas tend to call out to incident scenes more frequently than PCDs in urban areas. Further, the workloads are often less intense than in urban emergency primary care centres, which makes it easier for the rural PCDs to call out.
In rural areas, the PCDs work in the same local community as they live in, whilst urban GPs often only meet their patients in the course of their work. Due to relations to the local population, rural PCDs may have a stronger sense of loyalty to colleagues, patients and their relatives, and this may lower the threshold for them to call out to trauma incidents [26, 27]. As rural PCDs often know the patient population, a personal assessment with high-context communication at the incident scene may give better patient care. This could be an additional motivation for the PCDs to call out [28].
Severe trauma incidents are relatively rare in rural areas. When such an incident happens, it is common for the inhabitants of the community to be interested in the incident and discuss it afterwards. They may be interested in which personnel from the emergency services attended, including the PCD. This may lead to increased expectations of the PCDs regarding the right competence and participation in emergency care in the event of incidents in the local community [29].
Due to the higher number of patient contacts, Norwegian ambulance personnel working in urban areas are more experienced than those working in rural areas. Similar rural-urban differences have been reported in studies from other countries [30, 31]. In larger cities, there may be dedicated ambulances with anaesthetists who can call out to incidents with severe trauma [15]. With multiple health care resources available and short transport time and distance to the nearest trauma hospital, there may be less need for PCDs to call out to the incident scenes in urban areas.
In the present study, proportions of PCD call-outs to severe trauma incidents were significantly lower in the most urban regional Health Authority area compared to in two of the other regional Health Authority areas. This has not previously been investigated across all regional Health Authority areas in Norway within a single research study.
A Norwegian study from 2010 found that the GP call-out proportion when alerted by an emergency medical alarm from the EMCC ranged from 40 to 47%. The material was collected from three EMCCs in two different regional Health Authority areas [32]. These findings are comparable with three of the four Regional Health Authority areas in our study. Norway’s four regional Health Authority areas have variations in demographics. In the present study, we have adjusted for centrality and distance, and could argue that the observed differences between the four health trusts could also be related to variations in the organisation and planning of the prehospital trauma care. The PCDs are largely influenced by decisions made by the specialist health care system, even though they work in the primary health care system. The Regulation on the organisation of emergency services states that the municipalities and the Health Authority areas must ensure that the population in need of immediate help receives appropriate and coordinated emergency medical services outside hospitals [12].
Interestingly, we did not observe any significant differences in the proportions of PCD call-outs to severe trauma incidents according to time factors. In the adjusted analyses, neither time of the year, weekday or time of the day were significantly associated with PCD call-out. An American study observed no delay in acute trauma operations for patients admitted at night [33]. A well-functioning trauma system was suggested as the likely cause. A German study reported a slightly increased prehospital time delay for patients admitted at night, although there was no documented clinical impact. Increased prehospital time was related to time-consuming procedures and lower staffing levels at night [34]. PCDs could be expected to call out less frequently in the winter season when the weather is bad. Three different studies found differences in trauma incidents across seasons, but no differences in mortality [35,36,37]. The same studies observed that the use of health resources in trauma incidents in hospitals varied across seasons.
We found no significant difference in call-out rates across emergency primary care centres with or without rapid response vehicles. As we only have registrations from 2016 to 2018, further studies are needed to better clarify whether the availability of rapid response vehicles affects a PCD’s call-out to severe trauma incidents. It is possible that PCDs prefer to call out with an ambulance instead of a rapid response vehicle in cases of severe trauma incidents.
There was a substantial variation in proportions and rates of PCD call-outs to severe trauma incidents across the 16 EMCCs in Norway. There are large differences in demographics across these EMCC areas. We have documented that the call-out rates were affected by rural-urban factors. It is likely that differences in rural and urban EMCC areas could partly explain the variation in proportions and rates of call-outs. A Norwegian study from 2005 documented a significant difference, with an RR of 3.9, when comparing how often two EMCCs notified the GP in acute situations [27]. It also showed a significant difference, with an RR of 3.2, when comparing how often the GP worked within the geographical areas of these EMCCs, called out when notified. This variation was even greater in our study, with a difference in call out frequencies of more than tenfold across the EMCCs.
We can argue that the organisation of the EMCCs may have little impact on the work of the PCDs, as EMCCs and PCDs are organised in different parts of the health care system. Although PCDs work in the municipalities, they are influenced by the decisions of prehospital health personnel in the specialist health service. If the doctors are not alerted by the EMCCs about incidents with suspected severe trauma, it is not possible to call out. Future studies should investigate why there are such variations across the EMCCs.
This study is based on national registers that include all acute somatic hospital admissions from 2012 to 2018 [16]. By using this large data set, we avoided selection bias of sub-groups when we conducted our further analysis. The registries made it possible for us to investigate how variations in rural-urban settings and time factors were associated with PCD call-outs to severe trauma incidents in Norway. Previous studies have clearly demonstrated the connection between claims from emergency primary health care and hospital admissions less than 24 h later. This supports the design of this study. By using this method, our registers provide us with the number of call-outs and the total number of PCD engagements during the study period. This means that we can calculate with a high degree of certainty the percentage of call-outs when the PCDs were involved. Of 4,342 severe trauma incidents, we observed PCD involvement in 1,683 incidents. For the other 2,659 incidents (61%) we do not have any documented PCD involvement. It is highly probable that the PCDs were not involved.
According to the discharge diagnoses, these were cases of suspected severe trauma. The EMCC guidelines state that both the ambulance and PCD should be alarmed in cases of suspected severe trauma, and it would be concerning if many of these incidents were handled without any kind of alarm being sent to the PCD. A Second possibility could be that incidents involved a severe trauma with limited initial symptoms that were handled by a PCD clinic consultation or a telephone contact prior to an alarm from the EMCC to the ambulance. We recommend further studies to investigate the degree to which EMCCs send alarms to PCDs in the event of severe trauma incidents.
The registries used in our research did not include information about severely injured patients who died before admission or in the hospital. The Norwegian Cause of Death Registry reported 2.7% mortality due to trauma for the years 2012–2018, and the Norwegian Trauma Registry found 3.2% mortality 30 days after trauma for all patients admitted to Norwegian trauma hospitals for the years 2016–2018 [38, 39]. Consequently, deaths account for only a limited proportion of the overall trauma incidents. Probably, including dead trauma patients would have very small impact on the results.
At an early stage of severe trauma, the information in the primary message from the EMCC to the PCD and the ambulance is almost identical. It will be difficult to distinguish an incident where the patient dies later in the course from a patient who survives. Therefore, there is likely an equal frequency of call-outs from the PCD in both cases.
We used the patients’ home municipalities for distribution across the EMCCs. To ensure a more correct distribution, we should have used the municipalities in which the incident occurred. As we did not have access to that information, the actual distribution across the EMCCs may differ slightly from what we have reported. However, although the incident may not have happened within the patient’s own municipality, we think that it may relatively often have happened within the same geographical area of the EMCC.
Most injuries with an ICD-10 code in blocks S-T are due to minor injuries and can be handled within a lower emergency care level. It was important to ensure that we did not include minor injuries, which would not have triggered an acute alarm. We achieved this by including only significant multitrauma patients with DRG codes 484–487. It is a limitation of the study that injuries without these DRG codes were thereby excluded. A larger sample would have strengthened the statistical power of the study.
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