The Israeli Trauma system during wartime - policy and management.

On October 7, 2023, Hamas terrorists attacked people in their homes, fields, and at a music festival in Israeli communities near the border with Gaza. More than 1,145 men, women, and children were killed, about 1,800 wounded were evacuated to hospitals in the country, and 253 infants, children, women, elderly, and men were abducted. This mass casualty incident (MCI) was the start of a war that is still ongoing. The Israeli medical system, which faced an overwhelming first 24 h, continues to take care of casualties, including those who are injured by missiles that target Israeli residential areas.Israel has a well-established trauma system, and as a result of the experience gained in this war, the system merited review. This was the topic of a meeting of leaders of the Israeli healthcare system, and it forms the basis of this report. The meeting and report provide a platform for presenting the trauma system management during the war, highlighting the strengths of the system as well as its challenges and lessons learned. The participants also brainstormed and discussed possibilities for future improvements.

Overtriage of transfers to the pediatric trauma center: the importance of minor head injury.

OBJECTIVE: Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. METHODS: Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. RESULTS: There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. CONCLUSIONS: More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.

The relationship between patient volume and mortality in NSW major trauma service hospitals.

INTRODUCTION: Conventional wisdom is that Major Trauma Services (MTS) treating larger volumes of severe trauma patients will have better outcomes than lower volume centres, but recent studies from Europe have questioned this relationship. We aimed to determine if there is a relationship between patient volume and outcome in New South Wales (NSW) MTS hospitals. MATERIALS AND METHODS: Retrospective observational study using data from the NSW State Trauma Registry from 2010 to 2019 inclusive. Adult patients with Injury Severity Score >15 transported directly to a NSW MTS were included. Outcome measures were mortality at hospital discharge, and intensive care unit and hospital length of stay. Generalised estimating equation models were created to determine the adjusted relationship between patient volume and the main outcome measures. RESULTS: The mean annual patient volume of the MTS ranged from 127.4 to 282.0 patients whilst the observed mortality rates p.a. ranged from 10.4 % to 17.19 %. Multivariate analysis, using low volume MTS as the reference, did not demonstrate a significant difference in mortality between high and low volume MTS (adjusted OR: 1.14 95 % CI: 0.98-1.25, P = 0.087). There was however a significant correlation between volume and length of hospital stay (adjusted ß; 0.024, 95 % CI, 0.182 - 1.089, P = 0.006). CONCLUSIONS: There was no mortality difference between high and low volume MTS demonstrated. Length of hospital stay significantly increased with increasing volume however.

Effects of Trauma Center Consolidation on Adult Trauma at a Rural Level 1 Trauma Center.

OBJECTIVE: The aim was to determine the impact of consolidation of two rural level 1 trauma centers on adult trauma patients presenting to the remaining level 1 trauma center. To our knowledge, a study assessing the impact of trauma center consolidation on adult trauma patients had yet to be performed. METHODS: A single institution, retrospective study was conducted at a rural level 1 trauma center. Adult trauma patients who presented to our center from January 2017 to January 2022 were included. The cohorts spanned 33 months pre- and post-consolidation. Multiple demographic and outcome measures were gathered. Data were analyzed using the student's t-test and Chi-squared testing. RESULTS: There was a 33% increase in overall trauma activations and 9% increase in transfers from outside facilities post-consolidation. The post-consolidation group was significantly older, had higher mean injury severity score, and decreased hospital-free days. The post-consolidation group also saw an increase in ICU admission and surgical intervention. While there were no significant differences in ICU-free days or ventilator days, patients in the post-consolidation group with the highest level of activation who required both surgical intervention and ICU admission experienced decreased mortality. CONCLUSION: The consolidation of trauma services to a single level 1 trauma center in a rural Appalachian health system led to higher trauma volume and acuity, but most importantly decreased mortality for the most severely injured trauma patients.

Impact of lower level trauma center proliferation on patient outcomes.

Background: In attempt to increase trauma system coverage, our state added 21 level 3 (L3TC) and level 4 trauma centers (L4TC) to the existing 7 level 1 trauma centers from 2008 to 2012. This study examined the impact of adding these lower-level trauma centers (LLTC) on patient outcomes. Methods: Patients in the state trauma registry age ≥ 15 from 2007 to 2012 were queried for demographic, injury, and outcome variables. These were compared between 2007 (PRE) and 2008-2012 (POST) cohorts. Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were performed for Injury Severity Score (ISS) ≥15, age ≥ 65, and trauma mechanisms. Results: 143,919 adults were evaluated. POST had significantly more female, geriatric, and blunt traumas (all p < 0.001). ISS was similar. Interfacility transfers increased by 10.2 %. Overall mortality decreased by 0.6 % (p < 0.001). Multivariate logistic regression analysis showed that being in POST was not associated with survival (OR: 1.07, CI: 0.96-1.18, p = 0.227). Subgroup analyses showed small reductions in mortality, except for geriatric patients. After adjusting for covariates, POST was not associated with survival in any subgroup, and trended toward being a predictor for death in penetrating traumas (OR: 1.23; 1.00-1.53, p = 0.059). Conclusions: Unregulated proliferation of LLTCs was associated with increased interfacility transfers without significant increase in trauma patients treated. LLTC proliferation was not an independent protector against mortality in the overall cohort and may worsen mortality for penetrating trauma patients. Rather than simply increasing the number of LLTCs within a region, perhaps more planned approaches are needed. Key message: This is, to our knowledge, the first work to study the effect of rapid lower level trauma center proliferation on patient outcomes. The findings of our analysis have implications for strategic planning of future trauma systems.

Trauma systems in Asian countries: challenges and recommendations.

INTRODUCTION: Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries. METHOD: This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries. RESULT: Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting.

Getting patients to the right level of trauma center after motorcycle crashes in a rural trauma system.

PURPOSE: After a motorcycle crash (MCC), emergency medical services (EMS) responders must balance trauma center proximity with clinical needs of patients, which is especially challenging in rural states. The study purpose was to determine if MCC patients treated at lower-level trauma centers (LLTC) experienced higher mortality when compared to patients transported directly to the highest level of trauma care available in the state at Level II trauma centers. PROCEDURES: A retrospective study was conducted on MCC patients transported by EMS to Montana hospitals and met registry inclusion criteria in 2020-2021. The first study group included patients initially transported to state-designated trauma centers (equivalent to Level III-V) or non-designated hospitals (LLTC), and the second group included patients transported directly to American College of Surgeon verified Level II trauma centers (L2TC). Secondary transfer was defined as initial transport to a LLTC and subsequent transfer to a L2TC. Primary study outcome was mortality at the L2TC. Chi-square tests and Wilcoxon rank sum tests were used for analysis. FINDINGS: In the study period, 337 MCC patients were transported by EMS; 186 (55%) patients were transported to a LLTC while 151 patients (45%) were transported to a L2TC. There were no statistically significant differences in mortality (12% vs 8%, p = 0.30) when comparing secondary transfer patients to patients transported directly to a L2TC. CONCLUSIONS: Nearly half of patients initially evaluated at a LLTC required transfer to a higher-level of care. Secondary transfer was not associated with increased mortality.

Access to Trauma Care in a Rural State: A Descriptive Geographic and Demographic Analysis.

BACKGROUND: Montana is a rural state with limited access to higher-level trauma care; it also has higher injury fatality rates compared with the rest of the country. OBJECTIVES: The purpose of this study was to utilize Geographic Information System methodology to assess proximity to trauma care and identify the demographic characteristics of regions without trauma access. METHODS: Maptitude® Geographic Information System software (Caliper Corporation, Newton, MA) was used to identify regions in Montana within 60 min of trauma care; this included access to a Level II or Level III trauma center with general surgery capabilities and access to any level of trauma care. Demographic characteristics are reported to identify population groups lacking access to trauma care. RESULTS: Of the 1.1 million residents of Montana, 63% of residents live within 60 driving min of a higher-level trauma center, and 83% of residents live within 60 driving min of any level of trauma center. Elderly residents over age 65 years of age and American Indians had reduced access to both higher-level trauma care and any level trauma care. CONCLUSIONS: Prompt access to trauma care is significantly lower in Montana than in other parts of the country, with dramatic disparities for American Indians. In a rural state, it is important to ensure that all hospitals are equipped to provide some level of trauma care to reduce these disparities.

A Qualitative Study Exploring the Regional Feasibility of Patient-Reported Outcome Measures (PROMs) Data Collection for Orthopedic Trauma Patients.

INTRODUCTION: Behavioral health has been shown to impact both short- and long-term health outcomes in trauma patients. Recommendations for screening for behavioral health concerns in the acute setting exist, but longitudinal data collection is infrequently performed. The Trauma Quality Improvement Program describes the importance of patient-reported outcome measures (PROMs), including behavioral health data. METHODS: In this qualitative feasibility study, a multidisciplinary team participated in one-hour virtual focus groups; a semi-structured interview guide was used to ascertain feedback on a proposed PROMs study design. This study utilized a qualitative methodology to reveal thematic results from the staff feedback to determine the feasibility of the proposed study design. RESULTS: Three virtual one-hour focus groups consisting of a combination of seven trauma program managers and orthopedic practice managers were asked questions related to the feasibility of a PROMs study design before thematic saturation was reached. Through the analysis, four themes emerged: barriers, possible improvements, representation and research design. Themes included subthemes as well. Noteworthy results included the impact of an integrated orthopedic practice and the technological options available for use. CONCLUSION: This study revealed the barriers that would exist in the implementation of PROMs for orthopedic trauma patients, which may be useful when designing data collection procedures for PROMs. The results related to barriers may assist other trauma centers or regional trauma systems in designing an optimal methodology for PROMs data. Furthermore, the American College of Surgeons might consider these results prior to any mandated implementation of PROMs for trauma centers to avoid any possible burden on staff and systems.

Trauma Quality Improvement Program: A Retrospective Analysis from A Middle Eastern National Trauma Center.

BACKGROUND: The Trauma Quality Improvement Program (American College of Surgery (ACS-TQIP)) uses the existing infrastructure of the Committee on Trauma programs and provides feedback to participating hospitals on risk-adjusted outcomes. This study aimed to analyze and compare the performance of the Level I Hamad Trauma Centre (HTC) with other TQIP participating centers by comparing TQIP aggregate database reports. The primary goal was to pinpoint the variations in adult trauma outcomes and quality measures, identify areas that need improvement, and leverage existing resources to facilitate quality improvement. METHODS: A retrospective analysis was performed for the TQIP data from April 2019-March 2020 to April 2020-March 2021. We used the TQIP methodology, inclusion and exclusion criteria, and outcomes. RESULTS: There were 915 patients from Fall 2020 and 884 patients from Fall 2021 that qualified for the TQIP database. The HTC patients' demographics differed from the TQIP's aggregate data; they were younger, more predominantly male, and had significantly different mechanisms of injury (MOI) with more traffic-related blunt trauma. Penetrating injuries were more severe in the other centers. During the TQIP Fall 2020 report, the HTC was a low outlier (good performer) in one cohort (all patients) and an average performer in the remaining cohorts. However, during Fall 2021, the HTC showed an improvement and was a low outlier in two cohorts (all patients and severe TBI patients). Overall, the HTC remained an average performer during the report cycles. CONCLUSIONS: There was an improvement over time in the risk-adjusted mortality, which reflects the continuous and demanding effort put together by the trauma team. The ACS-TQIP for the external benchmarking of quality improvement could be a contributor to better monitored patient care. Evaluating the TQIP data with emphases on appropriate methodologies, quality measurements, corrective measures, and accurate reporting is warranted.

Door-to-Skin Time in Patient Undergoing Emergency Trauma Craniotomy.

Background: Traumatic brain injury (TBI) is the third leading cause of death and disability worldwide in 2020. For patients with TBI with significant intracranial bleeds, urgent surgical intervention remains the mainstay treatment. This study aims to evaluate the time to definite surgical intervention since admission and its association with patient outcomes in a neurosurgery referral centre in Malaysia. Methods: This retrospective study was conducted at Hospital Sultanah Aminah Johor Bahru from 1 January 2019 to 31 December 2019. All patients with TBI requiring urgent craniotomy were identified from the operating theatre registry, and the required data were extracted from their clinical notes, including the Glasgow Outcome Score (GCS) at discharge and 6 months later. Logistic regression was performed to identify the factors associated with poor outcomes. Results: A total of 154 patients were included in this study. The median door-to-skin time was 605 (interquartile range = 494-766) min. At discharge, 105 patients (68.2%) had poor outcomes. At the 6-month follow-up, only 58 patients (37.7%) remained to have poor outcomes. Simple logistic regression showed that polytrauma, hypotensive episode, ventilation, severe TBI, and the door-to-skin time were significantly associated with poor outcomes. After adjustments for the clinical characteristics in the analysis, the likelihood of having poor outcomes for every minute delay in the door-to-skin time increased at discharge (adjusted odds ratio [AOR] = 1.005; 95% confidence interval [CI] = 1.002-1.008) and the 6-month follow-up (AOR = 1.008; 95% CI = 1.005-1.011). Conclusion: The door-to-skin time is directly proportional to poor outcomes in patients with TBI. Concerted efforts from all parties involved in trauma care are essential in eliminating delays in surgical interventions and improving outcomes.

Geospatial Assessment to Improve Time to Treatment (GAITT).

INTRODUCTION: Geographic information systems (GIS) can optimize trauma systems by identifying ways to reduce time to treatment. Using GIS, this study analyzed a system in Maryland served by Johns Hopkins Suburban Hospital and the University of Maryland Capital Region Medical Center. It was hypothesized that including Walter Reed National Military Medical Center (WRNMMC) in the Maryland trauma system in an access simulation would provide increased timely access for a portion of the local population. MATERIALS AND METHODS: Using ArcGIS Online, catchment areas with and without WRNMMC were built. Catchment areas captured Johns Hopkins Suburban Hospital, University of Maryland Capital Region Medical Center, and WRNMMC at 5-, 10-, 15-, 20-, 25-, 30-, 45-, and 60-min. Various time conditions were simulated (12 am, 8 am, 12 pm, and 5 pm) on a weekday and weekend day. Data was enriched with 19 variables addressing population size, socioeconomic status, and diversity. RESULTS: All catchment areas benefited on at least one time-day simulation, but the largest increases in mean population coverage were in the 0-5 (10.5%), 5-10 (12.3%), and 10-15 min (5.7%) catchment areas. These areas benefited regardless of time-day simulation. The lowest increase in mean population coverage was seen in the 20-25-min catchment area (0.1%). Subgroup analysis revealed that all socioeconomic status and diversity groups gained coverage. CONCLUSIONS: This study suggests that incorporating WRNMMC into the Maryland trauma system might yield increased population coverage for timely trauma access. If incorporated, WRNMMC may provide nonstop or flexible coverage, possibly in different traffic scenarios or while civilian centers are on diversion status.

Challenges to the development of the trauma system in Egypt.

Trauma is a hidden disease in Egypt, and its significance on public health has been underestimated for decades. Road traffic accidents are the leading cause of injuries presented to hospitals in Egypt. Trauma systems in developed countries effectively reduced the morbidity and mortality associated with injuries in crowded cities. Developing a trauma system in Egypt is mandatory with the exploding population growth, increasing incidence of injuries, and the vast expansion of the infrastructures in the road network. However, the implementation of the trauma system in Egypt will not be devoid of challenges, including a lack of mandatory healthcare infrastructures such as adequate pre-hospital care, poor quality of data, and a shortage of adequately trained emergency physicians across the country.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial.

BACKGROUND: While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS: We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION: On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION: This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).

Care pathways and factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe traumatic brain injury: a population-based study from the Norwegian trauma registry.

BACKGROUND: Systems ensuring continuity of care through the treatment chain improve outcomes for traumatic brain injury (TBI) patients. Non-neurosurgical acute care trauma hospitals are central in providing care continuity in current trauma systems, however, their role in TBI management is understudied. This study aimed to investigate characteristics and care pathways and identify factors associated with interhospital transfer to neurotrauma centers for patients with isolated moderate-to-severe TBI primarily admitted to acute care trauma hospitals. METHODS: A population-based cohort study from the national Norwegian Trauma Registry (2015-2020) of adult patients (≥ 16 years) with isolated moderate-to-severe TBI (Abbreviated Injury Scale [AIS] Head ≥ 3, AIS Body < 3 and maximum 1 AIS Body = 2). Patient characteristics and care pathways were compared across transfer status strata. A generalized additive model was developed using purposeful selection to identify factors associated with transfer and how they affected transfer probability. RESULTS: The study included 1735 patients admitted to acute care trauma hospitals, of whom 692 (40%) were transferred to neurotrauma centers. Transferred patients were younger (median 60 vs. 72 years, P < 0.001), more severely injured (median New Injury Severity Score [NISS]: 29 vs. 17, P < 0.001), and had lower admission Glasgow Coma Scale (GCS) scores (≤ 13: 55% vs. 27, P < 0.001). Increased transfer probability was significantly associated with reduced GCS scores, comorbidity in patients < 77 years, and increasing NISSs until the effect was inverted at higher scores. Decreased transfer probability was significantly associated with increasing age and comorbidity, and distance between the acute care trauma hospital and the nearest neurotrauma center, except for extreme NISSs. CONCLUSIONS: Acute care trauma hospitals managed a substantial burden of isolated moderate-to-severe TBI patients primarily and definitively, highlighting the importance of high-quality neurotrauma care in non-neurosurgical hospitals. The transfer probability declined with increasing age and comorbidity, suggesting that older patients were carefully selected for transfer to specialized care.

The Geography of Injuries in Trauma Systems: Using Home as a Proxy for Incident Location.

INTRODUCTION: Effective trauma system organization is crucial to timely access to care and requires accurate understanding of injury and resource locations. Many systems rely on home zip codes to evaluate geographic distribution of injury; however, few studies have evaluated the reliability of home as a proxy for incident location after injury. METHODS: We analyzed data from a multicenter prospective cohort collected from 2017 to 2021. Injured patients with both home and incident zip codes were included. Outcomes included discordance and differential distance between home and incident zip code. Associations of discordance with patient characteristics were determined by logistic regression. We also assessed trauma center catchment areas based on home versus incident zip codes and variation regionally at each center. RESULTS: Fifty thousand one hundred seventy-five patients were included in the analysis. Home and incident zip codes were discordant in 21,635 patients (43.1%). Injuries related to motor vehicles (aOR: 4.76 [95% CI 4.50-5.04]) and younger adults 16-64 (aOR: 2.46 [95% CI 2.28-2.65]) were most likely to be discordant. Additionally, as injury severity score increased, discordance increased. Trauma center catchment area differed up to two-thirds of zip codes when using home versus incident location. Discordance rate, discordant distance, and catchment area overlap between home and incident zip codes all varied significantly by geographic region. CONCLUSIONS: Home location as proxy for injury location should be used with caution and may impact trauma system planning and policy, especially in certain populations. More accurate geolocation data are warranted to further optimize trauma system design.

The impact of road safety strategy and policy on admissions to a national rehabilitation hospital; a 5-year retrospective review and reflection on trauma data.

BACKGROUND: Globally, road traffic collisions (RTCs) are a common cause of death and disability. Although many countries, including Ireland, have road safety and trauma strategies, the impact on rehabilitation services is unclear. This study explores how admissions with RTC related injuries to a rehabilitation facility has changed over 5 years and how they contrast to major trauma audit (MTA) serious injury data from the same timeframe. METHODS: A retrospective review of healthcare records with data abstraction in accordance with best practice was performed. Fisher's exact test and binary logistic regression were used to determine associations and statistical process control was used to analyse variation. All patients discharged with an International Classification of Diseases (ICD) 10 coded diagnosis of Transport accidents from 2014 to 2018 were included. In addition, serious injury data was abstracted from MTA reports. RESULTS: 338 cases were identified. Of these, 173 did not meet the inclusion criteria (readmissions) and were excluded. The total number analyzed was 165. Of these, 121 (73%) were male and 44 (27%) were female and 115 (72%) were under 40 years of age. The majority [128 (78%)] had traumatic brain injuries (TBI), 33 (20%) had traumatic spinal cord injuries and 4 (2.4%) had traumatic amputation The numbers varied over the time period of the study but showed normal variation and not special cause variation which suggests no significant impact of policy in the time frame. There was a large discrepancy between the number of severe TBIs reported in the MTA reports and the numbers admitted with RTC related TBI to the National Rehabilitation University Hospital (NRH). This suggests there may be many people not accessing the specialist rehabilitation services they require. CONCLUSION: Data linkage between administrative and health datasets does not currently exist but offers huge potential for understanding the trauma and rehabilitation ecosystem in detail. This is required to better understand the impact of strategy and policy.

Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Analysis of mortality over 7 years in a mature trauma center: evolution of preventable mortality in severe trauma patients.

PURPOSE: The study of preventable trauma deaths is one mechanism used to examine the quality of care and outcomes of a trauma system. The present study aims to define the rate of preventable (PD) and potentially preventable death (PPD) in our mature trauma center, determine its leading causes, and evaluate the evolution of this rate over the years. METHODS: We performed a retrospective observational study in the Sainte Anne Military Teaching Hospital, Toulon (Var), France. From January 2013 to December 2020, all patients with severe trauma admitted to our trauma center and who died were analyzed. An independent group of 4 experts in the management of severe trauma performed the classification of deaths using a DELPHI method. RESULTS: During the study period, 180 deaths occurred among 2642 consecutive severe trauma patients (overall mortality 6.8%). 169 deaths were analyzed, Eleven (6.5%) were considered PD, and thirty-eight (22.1%) were PPD. 69 errors were identified. The most frequent errors were in pre-hospital (excessive pre-hospital times 33.3% and inadequate management 29%). Time before surgery was considered excessive in 15.9% of cases. Over the study period, the rates of PD and PPD deaths remained stable. CONCLUSION: PD and PPD rates are still high and do not decrease over the years in our mature trauma center. It confirms the need for progress in the management of severe trauma patients. Reducing the time to provide care seems to be the main area for improvement. Further studies will be necessary to better target the points to be improved.