S. L. Kumar1, J. Song1, P. M. Reilly1, E. T. Dickinson1, D. G. Buckler2, E. J. Kaufman1 1University of Pennsylvania – Perelman School of Medicine, Philadelphia, PENNSYLVANIA, USA 2Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction:
Expedient access to specialized trauma care can be lifesaving for acutely injured patients. Although rapid transport within an organized trauma system is critical, the United States trauma system is decentralized and state-based. The role of trauma transport across state borders has not been established and may be limited by insurance reimbursement policies and EMS protocols or practices. For patients living in areas near state borders, herein referred to as cross-border areas, the nearest trauma center may be out-of-state rather than in-state. If patients are preferentially kept in-state, prehospital time may be extended. This study investigates the challenge posed by state borders by identifying the population, injury, and geographic scope of areas of the country where the closest trauma center is out-of-state, and by collating state EMS policies relevant to cross-border trauma transport.
Methods:
We identified Level I and II trauma centers across the contiguous U.S. using the American Trauma Society’s 2020 Trauma Information Exchange Program. ArcGIS Desktop 10.8 was used to map the distribution of designated trauma centers across the U.S. County centroids, determined using geographic data from the U.S. Census Bureau, were utilized to identify the nearest designated Level I or II trauma center to each county. Straight line distances were used to approximate shortest possible transport times, including air transport. State EMS protocols were collected from publicly-available documents and were categorized as encouraging, discouraging, or neutral on cross-border transport, or as leaving the matter to local discretion. The National Highway Traffic Safety Administration Fatality Analysis Report System was queried to quantify the proportion of fatal crashes occurring in the areas of interest.
Results:
Of 3,108 included U.S. counties, 639 (20.6%) were closest to an out-of-state designated Level I or II trauma center (see figure). These counties accounted for 6.7% of the U.S. population and 9.4% of all motor vehicle fatalities. Of the 48 contiguous states, 30 encourage cross-border transport, 2 discourage it, 12 are neutral, and 4 leave it to local discretion.
Conclusion:
Cross-border transport of injured patients has the potential to expedite access to care in over 1 in 5 U.S. counties. While few state EMS protocols discourage this practice, more robust policy guidance for cross-border prehospital transport and payment could reduce delays and bridge gaps in care.
