Codeveloping theories of change for improved community-based violence intervention evaluation.

BACKGROUND: Community-based violence intervention (CVI) programs are considered important strategies for preventing community violence and promoting health and safety. Mixed and inconclusive results from some prior CVI evaluations, as well as our general lack of understanding about the reasons for such varied findings, may be explained in part by misalignment of program theories of change and evaluation measures. Furthermore, most prior evaluations have focused solely on deficit-based outcomes; this narrow focus is inconsistent with the premise of CVI and may fail to capture improvements in health and well-being that are on the hypothesized pathway from intervention to violence reduction. METHODS: This article describes the process and results of codeveloping a theory of change for community-based youth firearm violence intervention and prevention programs in Washington state through a community-researcher partnership. We followed a multistep iterative process, involving (1) CVI program documentation review, (2) individual meetings, and (3) a day-long workshop. RESULTS: The theory of change included six key domains: (1) root causes, (2) promotive factors, (3) activities, (4) intermediate outcomes, (5) longer-term outcomes, and (6) multilevel context (youth/family, staff/organizational, community, and societal). Root causes were social and structural drivers of community violence. Promotive factors were assets and resources among the community, youth/their families, and community organizations that promote health and safety. Activities were supports and services the program provided to youth and their families, staff, and, potentially, the broader community. Intermediate and longer-term outcomes were the changes among youth, their families, staff, and the community that resulted from program activities. Intermediate outcomes may be felt within 6 months to 1 year, and longer-term outcomes may be felt after 1 to 2 years and beyond. CONCLUSION: The theory of change we codeveloped provides a common lens to conceptualize, compare, and evaluate CVI programs in Washington state and may support more rigorous and equity-centered evaluations. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level V.

A Clinician's Guide to Conducting Research on Causal Effects.

Surgeons are uniquely poised to conduct research to improve patient care, yet a gap often exists between the clinician's desire to guide patient care with causal evidence and having adequate training necessary to produce causal evidence. This guide aims to address this gap by providing clinically relevant examples to illustrate necessary assumptions required for clinical research to produce causal estimates.

Helping individuals with firearm injuries: A cluster randomized trial.

BACKGROUND: Patients with firearm injuries are at high risk of subsequent arrest and injury following hospital discharge. We sought to evaluate the effect of a 6-month joint hospital- and community-based low-intensity intervention on risk of arrest and injury among patients with firearm injuries. METHODS: We conducted a cluster randomized controlled trial, enrolling patients with firearm injuries who received treatment at Harborview Medical Center, the level 1 trauma center in Seattle, Washington, were 18 years or older at the time of injury, spoke English, were able to provide consent and a method of contact, and lived in one of the five study counties. The intervention consisted of hospital-based motivational interviewing, followed by a 6-month community-based intervention, and multiagency support. The primary outcome was the risk of subsequent arrest. The main secondary outcome was the risk of death or subsequent injury requiring treatment in the emergency department or hospitalization. RESULTS: Neither assignment to or engagement with the intervention, defined as having at least 1 contact point with the support specialist, was associated with risk of arrest at 2 years post-hospital discharge (relative risk for intervention assignment, 1.15; 95% confidence interval, 0.90-1.48; relative risk for intervention engagement, 1.07; 95% confidence interval, 0.74-2.19). There was similarly no association observed for subsequent injury. CONCLUSIONS: This study represents one of the first randomized controlled trials of a joint hospital- and community-based intervention delivered exclusively among patients with firearm injuries. The intervention was not associated with changes in risk of arrest or injury, a finding most likely due to the low intensity of the program. LEVEL OF EVIDENCE: Care management, level II.

Concomitant Upper Extremity Fracture Worsens Outcomes in Elderly Patients With Hip Fracture.

BACKGROUND: Elderly patients with low-energy hip fractures have high rates of morbidity and mortality, but it is not well known how often concurrent upper extremity fractures occur and how this impacts outcomes. We used the National Trauma Databank (NTDB), the largest aggregation of US trauma registry data available, to determine whether patients with concurrent upper extremity and hip fractures have worse outcomes than patients with hip fractures alone. METHODS: We accessed the NTDB to identify patients aged 65 to 100 who sustained a hip fracture. The cohort was then narrowed to include only patients who sustained their injury in a fall and had an injury severity score indicating hip fracture as the most severe injury. We then analyzed this group to assess the impact of a simultaneous upper extremity fracture on length of stay, in-hospital mortality, and discharge disposition. RESULTS: From 2007 to 2014, a total of 231,299 patients aged 65 to 100 were identified as having a hip fracture. The narrowed cohort with fall as the mechanism and hip fracture as the most severe injury included 193,862 patients. Of these, 12,618 patients sustained a concomitant upper extremity fracture (6.5%). Compared to isolated hip fractures, patients with a concomitant upper extremity fracture had higher odds of death in the hospital (odds ratio [OR] = 1.3; 95% confidence interval = 1.2-1.4), were less likely to be discharged to home as compared to a skilled facility (OR = 0.73; 95% confidence interval = 0.68-0.78), and had a significantly longer average length of stay (7.1 vs 6.4 days, P < .001). CONCLUSIONS: We found a 6.5% prevalence of concomitant upper extremity fractures in patients aged 65 to 100 with a hip fracture sustained after a fall where the hip fracture was the most severe injury. These patients had a higher risk of in-hospital mortality, were less likely to be discharged to home, and had longer average length of stay.

Transfer and nontransfer patients in isolated low-grade blunt pediatric solid organ injury: Implications for regionalized trauma systems.

BACKGROUND: Regionalization of trauma care is a national priority and hospitalization for blunt abdominal trauma, which may include transfer, is common among children. The objective of this study was to determine whether there were differences in mortality, treatment, or length of stay between patients treated at or transferred to a higher level trauma center and those not transferred and admitted to a lower level trauma center. METHODS: Cohort from Washington state trauma registry from 2000 to 2014 of patients 16 years or younger with isolated Grade I-III spleen, liver, or kidney injury. RESULTS: Among 54,034 patients 16 years or younger, the trauma registry captured 1177 (2.2%) patients with isolated low grade solid organ injuries; 226 (19.2%) presented to a higher level trauma center, 600 (51.0%) presented to a lower level trauma center and stayed there for care, and 351 (29.8%) were transferred to a higher level trauma center. Forty (3.4%) patients underwent an abdominal operation. Among the 950 patients evaluated initially at a lower level trauma center, the risk of surgery did not differ significantly between those who were not transferred compared to those who were (relative risk, 2.19; 95% confidence interval, 0.80-6.01). The risk of total splenectomy was no different for patients who stayed at a lower level trauma center compared with those who were transferred to a higher level trauma center (RR, 0.84; 95% CI, 0.33-2.16). Nontransferred patients had a 0.63 (95% confidence interval, 0.45-0.88) times lower risk of staying in the hospital for an additional day compared with patients who were transferred to a higher level trauma center. One patient died. CONCLUSION: Few pediatric patients with isolated low grade blunt solid organ injury require intervention and thus may not need to be transferred; trauma systems should revise their transfer policies. Prevention of unnecessary transfers is an opportunity for cost savings in pediatric trauma. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Critical Care Resource Utilization and Outcomes of Children With Moderate Traumatic Brain Injury.

OBJECTIVES: To characterize admission patterns, critical care resource utilization, and outcomes in moderate pediatric traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: National Trauma Data Bank. PATIENTS: Children under 18 years old with a diagnosis of moderate traumatic brain injury (admission Glasgow Coma Scale score of 9-13) in the National Trauma Data Bank between 2007 and 2014. MEASUREMENT AND MAIN RESULTS: We examined clinical characteristics, critical care resource utilization, and discharge outcomes. Poor outcomes were defined as discharge to hospice, skilled nursing facility, long-term acute care, or death. We examined 20,010 patient records. Patients were 9 years old (interquartile range, 2-15 yr), male (64%) with isolated traumatic brain injury (81%), Glasgow Coma Scale score of 12, head Abbreviated Injury Scale score of 3, and Injury Severity Score of 10. Majority (34%) were admitted to nontrauma hospitals. Critical care utilization was 58.7% including 11.5% mechanical ventilation and 3.2% intracranial pressure monitoring. Compared to patients with Glasgow Coma Scale score of 13, admission Glasgow Coma Scale score of 9 was associated with greater critical care resource utilization, such as ICU admission (72% vs 50%), intracranial pressure monitoring (7% vs 1.8%), mechanical ventilation (21% vs 6%), and intracranial surgery (10% vs 5%). Most patients (70%) were discharged to home, but up to one third had poor outcomes. Older age group had a higher risk of poor outcomes (10-14 yr; adjusted relative risk, 1.32; 95% CI, 1.13-1.54; 15-17 yr; adjusted relative risk, 2.39; 95% CI, 2.12-2.70). Poor outcomes occurred with lower Glasgow Coma Scale (Glasgow Coma Scale score of 9 vs Glasgow Coma Scale score of 13: adjusted relative risk, 2.89; 95% CI, 2.47-3.38), higher Injury Severity Score (Injury Severity Score of ≥ 16 vs Injury Severity Score of < 9: adjusted relative risk, 8.10; 95% CI 6.27-10.45), and polytrauma (adjusted relative risk, 1.40; 95% CI, 1.22-1.61). CONCLUSIONS: Critical care resources are used in more than half of all moderate pediatric traumatic brain injury, and many receive care at nontrauma hospitals. Up to one third of moderate pediatric traumatic brain injury have poor outcomes, risk factors for which include age greater than 10 years, lower admission Glasgow Coma Scale, higher Injury Severity Score, and polytrauma. There is urgent need to optimize triage, care, and outcomes in this vulnerable population.

Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients.

BACKGROUND: Current guidelines recommend routine clamping of external ventricular drains (EVD) for intrahospital transport (IHT). The aim of this project was to describe intracranial hemodynamic complications associated with routine EVD clamping for IHT in neurocritically ill cerebrovascular patients. METHODS: We conducted a retrospective review of cerebrovascular adult patients with indwelling EVD admitted to the neurocritical care unit (NICU) during the months of September to December 2015 at a tertiary care center. All IHTs from the NICU of the included patients were examined. Main outcomes were incidence and risk factors for an alteration in intracranial pressure (ICP) and cerebral perfusion pressure after IHT. RESULTS: Nineteen cerebrovascular patients underwent 178 IHTs (79.8 % diagnostic and 20.2 % therapeutic) with clamped EVD. Twenty-one IHTs (11.8 %) were associated with post-IHT ICP ≥ 20 mmHg, and 33 IHTs (18.5 %) were associated with escalation of ICP category. Forty IHTs (26.7 %) in patients with open EVD status in the NICU prior to IHT were associated with IHT complications, whereas no IHT complications occurred in IHTs with clamped EVD status in the NICU. Risk factors for post-IHT ICP ≥ 20 mmHg were IHT for therapeutic procedures (adjusted relative risk [aRR] 5.82; 95 % CI, 1.76-19.19), pre-IHT ICP 15-19 mmHg (aRR 3.40; 95 % CI, 1.08-10.76), pre-IHT ICP ≥ 20 mmHg (aRR 12.94; 95 % CI, 4.08-41.01), and each 1 mL of hourly cerebrospinal fluid (CSF) drained prior to IHT (aRR 1.11; 95 % CI, 1.01-1.23). CONCLUSIONS: Routine clamping of EVD for IHT in cerebrovascular patients is associated with post-IHT ICP complications. Pre-IHT ICP ≥ 15 mmHg, increasing hourly CSF output, and IHT for therapeutic procedures are risk factors.