A Window of Opportunity: Understanding Pediatric Falls Using Area Deprivation Index.

INTRODUCTION: The purpose of our study is to assess neighborhood socioeconomic disadvantage (NSD) as a risk factor for window falls (WF) in children. METHODS: A single institution retrospective review was performed of patients ≤18 years old with fall injuries treated at a Level I trauma center between 2018 and 2021. Demographic, injury, and NSD characteristics which were collected from a trauma registry were analyzed and compared between WF versus non-window falls. Area Deprivation Index (ADI) was used to measure NSD levels based on patients' home address 9-digit zip code, with greater NSD being defined as ADI quintiles 4 and 5. Property type was used to compare falls that took place at single-family homes versus apartment buildings. RESULTS: Among 1545 pediatric fall injuries, 194 were WF, of which 60 % were male and 46 % were Hispanic. WF patients were younger than NWF patients (median age WF 3.2 vs. age 4.3, p<0.047). WF patients were more likely to have a depressed Glasgow Coma Scale (GCS score ≤12, WF 9 % vs. 3 %) and sustain greater head/neck injuries (median AIS 3vs. AIS 2, p<0.001) when compared to NWF. WF patients had longer hospital and ICU lengths of stay than NWF patients (p<0.001 and p<0.001, respectively). WF patients were more likely to live in areas of greater NSD than NWF patients (53 % vs. 35 %, p<0.001), and 73 % of all WF patients lived in apartments or condominiums. CONCLUSIONS: Window fall injuries were associated with lower GCS, greater severity of head/neck injuries, and longer hospital and ICU length of stay than non-window falls. ADI research can provide meaningful data for targeted injury prevention programs in areas where children are at higher risk of window falls. STUDY TYPE: Retrospective review. LEVEL OF EVIDENCE: III.

Up and over: Consequences of raising the United States-Mexico border wall height.

OBJECTIVES: San Diego County's geographic location lends a unique demographic of migrant patients injured by falls at the United States-Mexico border. To prevent migrant crossings, a 2017 Executive Order allocated funds to increase the southern California border wall height from 10 ft to 30 ft, which was completed in December 2019. We hypothesized that the elevated border wall height is associated with increased major trauma, resource utilization, and health care costs. METHODS: Retrospective trauma registry review of border wall falls was performed by the two Level I trauma centers that admit border fall patients from the southern California border from January 2016 to June 2022. Patients were assigned to either "pre-2020" or "post-2020" subgroups based upon timing of completion of the heightened border wall. Total number of admissions, operating room utilization, hospital charges, and hospital costs were compared. RESULTS: Injuries from border wall falls grew 967% from 2016 to 2021 (39 vs. 377 admissions); this percentage is expected to be supplanted in 2022. When comparing the two subgroups, operating room utilization (175 vs. 734 total operations) and median hospital charges per patient ($95,229 vs. $168,795) have risen dramatically over the same time period. Hospital costs increased 636% in the post-2020 subgroup ($11,351,216 versus $72,172,123). The majority (97%) of these patients are uninsured at admission, with costs largely subsidized by federal government entities (57%) or through state Medicaid enrollment postadmission (31%). CONCLUSION: The increased height of the United States-Mexico border wall has resulted in record numbers of injured migrant patients, placing novel financial and resource burdens on already stressed trauma systems. To address this public health crisis, legislators and health care providers must conduct collaborative, apolitical discussions regarding the border wall's efficacy as a means of deterrence and its impact on traumatic injury and disability. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Financial vulnerability of trauma centers: A national analysis.

OBJECTIVE: Trauma centers function as an essential safeguard in the United States health care system. However, there has been minimal study of their financial health or vulnerability. We sought to perform a nationwide analysis of trauma centers using detailed financial data and a recently developed Financial Vulnerability Score (FVS) metric. METHODS: The RAND Hospital Financial Database was used to evaluate all American College of Surgeons-verified trauma centers nationwide. The composite FVS was calculated for each center using six metrics. Financial Vulnerability Score tertiles were used to classify centers as high, medium, or low vulnerability, and hospital characteristics were analyzed and compared. Hospitals were also compared by US Census region and teaching versus nonteaching hospitals. RESULTS: A total of 311 American College of Surgeons-verified trauma centers were included in the analysis, with 100 (32%) Level I, 140 (45%) Level II, and 71 (23%) Level III. The largest share of the high FVS tier was consisted of Level III centers (62%), with the majority of Level I (40%) and Level II (42%) in the middle and low FVS tier, respectively. The most vulnerable centers had fewer beds, negative operating margins, and significantly less cash on hand. Lower FVS centers had greater asset/liability ratios, lower outpatient shares, and three times less uncompensated care. Nonteaching centers were statistically significantly more likely to have high vulnerability compared with teaching centers (46% vs. 29%). Statewide analysis showed high discrepancy among individual states. CONCLUSION: With approximately 25% of Levels I and II trauma centers at high risk for financial vulnerability, disparities in characteristics, including payer mix and outpatient status, should be targeted to reduce vulnerabilities and bolster the health care safety net. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Financial Vulnerability of American College of Surgeons-Verified Trauma Centers: A Statewide Analysis.

BACKGROUND: Although trauma centers represent an integral part of healthcare in the US, characterization of their financial vulnerability has not been reported. We sought to characterize the financial health and vulnerability among California trauma centers and identify factors associated with high and low vulnerability. STUDY DESIGN: The RAND Hospital Data financial dataset was used to evaluate all American College of Surgeons (ACS)-verified trauma centers in California. Financial vulnerability of each center was calculated using 6 metrics to calculate a composite Financial Vulnerability Score (FVS). Tertiles of the FVS were generated to classify trauma centers as high, medium, or low financial vulnerability. Hospital characteristics were also analyzed and compared. RESULTS: Forty-seven ACS trauma centers were identified. Nine were Level I, 27 were Level II, and 8 were Level III. Level I centers encompassed the greatest proportion of the high FVS tier (44%), whereas Level II and III centers were the most likely to be in the middle and lower tiers, respectively (44%; 63%). Lower FVS centers had greater asset:liability ratios, operating margins, and days cash on hand compared with the 2 higher tiers, whereas high FVS centers showed a greater proportion of uncompensated care, outpatient share rates, outpatient surgeries, and longer days in net accounts. Lower FVS centers were more likely to be teaching hospitals and members of a larger corporate entity. CONCLUSION: Many ACS trauma centers are at moderate/high risk for financial vulnerability and disparate impacts of stressor events, and the FVS may represent a novel metric that could be used at the local or statewide level.

Integrating traffic safety data with area deprivation index: A method to better understand the causes of pediatric pedestrian versus automobile collisions.

BACKGROUND: The purpose of this study was to identify clinical and traffic factors that influence pediatric pedestrian versus automobile collisions (P-ACs) with an emphasis on health care disparities. METHODS: A retrospective review was performed of pediatric (18 years or younger) P-ACs treated at a Level I pediatric trauma center from 2008 to 2018. Demographic, clinical, and traffic scene data were analyzed. Area deprivation index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) based on home addresses. Traffic scene data from the California Statewide Integrated Traffic Records System were matched to clinical records. Traffic safety was assessed by the streetlight coverage, the proximity of the collision to home addresses, and sidewalk coverage. Descriptive statistics and univariate analysis for key variables and outcomes were calculated using Kruskal-Wallis, Wilcoxon, χ 2 , or Fisher's exact tests. Statistical significance was attributed to p values of <0.05. RESULTS: Among 770 patients, the majority were male (65%) and Hispanic (54%), with a median age of 8 years (interquartile range, 4-12 years). Hispanic patients were more likely to live in more disadvantaged neighborhoods than non-Hispanic patients (67% vs. 45%, p < 0.01). There were no differences in clinical characteristics or outcomes across ADI quintiles. Using the Statewide Integrated Traffic Records System (n = 272), patients with more NSD were more likely injured during dark streetlight conditions (15% vs. 4% least disadvantaged; p = 0.04) and within 0.5 miles from home ( p < 0.01). Pedestrian violations were common (65%). During after-school hours, 25% were pedestrian violations, compared with 12% driver violations ( p = 0.02). CONCLUSION: A larger proportion of Hispanic children injured in P-ACs lived in neighborhoods with more socioeconomic disadvantage. Hispanic ethnicity and NSD are each independently associated with P-ACs. Poor streetlight conditions and close proximity to home were associated with the most socioeconomically disadvantaged neighborhoods. This research may support targeted prevention programs to improve pedestrian safety in children. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Why Trauma Care is Not Expensive: Detailed Analysis of Actual Costs and Cost Differences of Patient Cohorts.

BACKGROUND: Trauma patients are resource intensive, requiring a variety of medical and procedural interventions during hospitalization. These expenses often label trauma care as "high cost" based on gross hospital charges. We hypothesized that a financial metric built on actual costs and clinically relevant trauma patient cohorts would demonstrate a lower true cost of trauma care than the standardly reported gross hospital charges. METHODS: We examined all trauma patients (≥16 yr) treated in 2017 from a single institution and matched them to the institution's detailed financial accounting data. The organization's Financial Operations Division is uniquely able to allocate total operating costs across patient encounters to include medications, procedures, and salaries/fees from medical professionals and administrators. Patient subgroups were identified by Trauma Quality Improvement Program (TQIP) criteria for cost comparisons. RESULTS: Overall median cost per patient was $6,544 [IQR $4,975-14,532] for 2,548 patients. The median cost per patient increased with Injury Severity Score (ISS) ranging from $5,457(ISS ≤ 7) to $34,898(ISS ≥ 21), each accompanied by an average 548% increase in gross charges. Costs also varied widely from $13,498 [IQR $8,247-26,254] to $45,759 [IQR $22,186-113,993] across TQIP patient cohorts. Of the total cost, 91% was attributed to personnel alone. DISCUSSION: Measuring the true cost of trauma care is feasible. As hypothesized, the true cost of trauma care is lower than charges. True cost increased with injury severity with variable cost across subgroups. Non-physician staff and administration are the largest component of the cost of trauma care.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention.

INTRODUCTION: There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries. METHODS: Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage. RESULTS: Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage. CONCLUSIONS: Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Pediatric trauma in the California-Mexico border region: Injury disparities by Area Deprivation Index.

BACKGROUND: The California-Mexico border region is a high-volume trauma area with populations of widely disparate socioeconomic status. This work analyzed differences in demographics and mechanism of injury in children using the Area Deprivation Index (ADI), a composite measure of 17 markers of neighborhood socioeconomic disadvantage. METHODS: A retrospective review was performed of pediatric patients evaluated at the regional Level I Pediatric Trauma Center between 2008 and 2018. Collected data included patient demographics and injury characteristics. Patient addresses were correlated to neighborhood disadvantage level using ADI quintiles, with a higher quintile representing greater socioeconomic disadvantage. RESULTS: A total of 9,715 children were identified, of which 4,307 (44%) were Hispanic. Hispanic children were more likely to live in more disadvantaged neighborhoods than non-Hispanic children (p < 0.001). There were markedly different injury mechanisms in neighborhoods with greater socioeconomic disadvantage (higher ADI) compared with those with less socioeconomic disadvantage. Sports-related and nonmotorized vehicular trauma predominated in less disadvantaged neighborhoods, while higher ADI quintiles were strongly associated with pedestrian versus automobile, motorized vehicle accidents/collisions, and nonaccidental injuries (p < 0.001). CONCLUSION: This analysis represents the first study to characterize pediatric traumatic injury patterns based upon the neighborhood ADI metric. Area Deprivation Index can be a useful resource in identifying disparities in pediatric trauma and children at increased risk for vehicular and abusive injury who may benefit from increased resource allocation, social support, and prevention programs. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

A tale of two centers: Is low-molecular-weight heparin really superior for prevention of posttraumatic venous thromboembolism?

BACKGROUND: Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS: Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. RESULTS: There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. CONCLUSION: Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. LEVEL OF EVIDENCE: Prognostic and epidemiological, level II; Therapeutic, level III.

Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown. METHODS: Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality. RESULTS: Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72). CONCLUSIONS: Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

Quantifying the burden of pre-existing conditions in older trauma patients: A novel metric based on mortality risk.

INTRODUCTION: Pre-existing medical conditions (PEC) represent a unique domain of risk among older trauma patients. The study objective was to develop a metric to quantify PEC burden for trauma patients. METHODS: A cohort of 4526 non-severe blunt-injured trauma patients aged 55 years and older admitted to a Level I trauma center between January 2006 and December 2012 were divided into development (80%) and test (20%) sets. Cox regression was used to develop the model based on in-hospital and 90-day mortality. Regression coefficients were converted into a point-based PEC Risk Score. Performance of the PEC Risk Score was compared in the test set with two other PEC-based metrics and three injury-based metrics. An external cohort of 2284 trauma patients admitted in 2013 was used to evaluate combined metric performance. RESULTS: Total mortality was 9.4% and 9.1% in the development and test set, respectively. The final model included 12 PEC. In the test set, the PEC Risk Score (c-statistic: 79.7) was superior for predicting in-hospital and 90-day mortality compared with all other metrics. For in-hospital mortality alone, the PEC Risk Score similarly outperformed all other metrics. Combination of the PEC Risk Score and any injury-based metric significantly improved prediction compared with any injury-based metric alone. CONCLUSION: Our 12-item PEC Risk Score performed well compared with other metrics, suggesting that the classification of trauma-related mortality risk may be improved through its use. Among non-severely injured older trauma patients, the utility of prognostic metrics may be enhanced through the incorporation of comorbidities.

Quantitative assessment of intestinal injury using a novel in vivo, near-infrared imaging technique.

Intestinal injury owing to inflammation, severe trauma, and burn is a leading cause of morbidity and mortality. Currently, animal models employed to study the intestinal response to injury and inflammation depend on outdated methods of analysis. Given that these classic intestinal assays are lethal to the experimental animal, there is no ability to study the gut response to injury in the same animal over time. We postulated that by developing an in vivo assay to image intestinal injury using fluorescent dye, it could complement other expensive, time-consuming, and semiquantitative classic means of detecting intestinal injury. We describe a novel in vivo, noninvasive method to image intestinal injury using a charge-coupled device (CCD) camera that allows for serial visual and quantitative analysis of intestinal injury. Our results correlate with traditional, time-consuming, semiquantitative assays of intestinal injury, now allowing the noninvasive, nonlethal assessment of injury over time.