Recent release from prison - A novel risk factor for intimate partner homicide.

BACKGROUND: The United States has the highest per-capita incarceration rate and the largest prison population in the world. More than two thirds of recently incarcerated individuals will be arrested again within 3 years of release and may commit crimes as serious as homicide soon after discharge. The pattern of homicidal violence currently remains unknown for recently incarcerated homicide suspects (RIHS) and their victims. METHODS: A retrospective analysis of the 36 states included in the 2003 to 2017 National Violent Death Reporting System was performed with a focus on RIHS and their victims. Pearson χ2 and Wilcoxon rank sum tests were used for comparison. RESULTS: There were 249 RIHS in the database of the 14,561 homicides where suspect recent incarceration status was documented. Compared with not-recently incarcerated suspects, RIHS were more likely to be White (41% vs. 29%, p < 0.001) and male (97% vs. 91%, p < 0.001). Recently incarcerated homicide suspects more often had a known relationship with the victim (75% vs. 51%, p < 0.001), and these homicides more often occurred in the victim's own home (43% vs. 34%, p = 0.006). Intimate partner violence was a factor in 31% of the RIHS cases (vs. 17%, p < 0.001). The homicide weapon was most likely to be a firearm (57.8%, p < 0.001). Only 6.4% of homicides were due to mental health illness. Gang violence, while more common in the RIHS group, was still only a precipitating factor in 12.0% of the homicides (vs. 7.4%, p = 0.006). CONCLUSION: Recently incarcerated homicide suspects are more likely to kill a known person in their own home with a firearm, and these homicides are frequently categorized as intimate partner homicides. Gang violence and mental health are not frequent precipitating factors in these deaths. Additional future interventions are urgently needed to eliminate these preventable deaths by alerting previous or current intimate partners of those being discharged from the prison system.

Level I Trauma Centers: More Is Not Necessarily Better.

The optimal number of level I trauma centers (L1TCs) in a region has not been elucidated. To begin addressing this, we compared mortalities for patients treated in counties or regions with 1 L1TC to those with >1 L1TC across Ohio. Ohio Trauma Registry data from 2010 to 2012 were analyzed. Patients with age ≥15 from counties/regions with L1TC were included. Region was defined as a L1TC containing county and its neighboring counties. Two analyses were performed. In the county analysis, counties containing 1 L1TC were compared with counties with multiple L1TCs. This comparison is repeated on a regional level for the regional analysis. Subgroup analyses were performed. 38,661 and 55,064 patients were in the county and regional analysis, respectively. Patients treated in counties or regions with multiple L1TCs were significantly younger (P < 0.001). Despite this, the mortality was similar for the two groups in the county analysis and significantly higher for regions with multiple L1TCs (P < 0.001). Multivariate logistic regression demonstrated that having multiple L1TC coverage in a region was an independent predictor for death (odds ratios: 1.17; 1.07-1.28; P = 0.001). Subgroup analyses showed that mortality in counties and regions with multiple L1TCs was not lower in any subgroups but was higher in patients with age ≥65 and patients with blunt injuries (P < 0.05). Having multiple L1TCs in a county was associated with increased mortality in certain patient subgroups. Having multiple L1TCs in a region was an independent predictor for death. These results should be considered carefully when designing future regionalized trauma networks. More L1TCs is not necessarily better.

Statewide Analysis Shows Collaborative Regional Trauma Network Reduces Regional Mortality.

A Regional Trauma Network (RTN), composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems, was established in 2010. This collaborative network used a unified triage protocol and a single transfer center. The impact of this RTN was assessed by evaluating regional mortality changes before and after RTN establishment. Patients in the state trauma registry aged 15 and older from 2006 to 2012 were analyzed; 2006 to 2009 and 2010 to 2012 were designated as pre-RTN and RTN periods, respectively. The region was defined as a county containing L1TC and its adjacent counties. Any counties bordering multiple L1TC-containing counties were excluded from analysis. Mortality was compared for all regions before and after RTN implementation. The following subgroups were also included a priori for the comparison: Injury Severity Score ≥15, age ≥65, and trauma mechanisms. 121,448 patients were analyzed; 66,977 and 54,471 patients were in the pre-RTN and RTN groups, respectively. Mean age was 58; 90 per cent had blunt injuries. The overall mortality was 4.9 per cent. Mortality comparisons over time for all regions are presented. The RTN region was the only region in the state that had mortality reduction in all patient subgroups. After adjusting for age, Injury Severity Score, level of TC that performed treatment, and trauma mechanism, RTN implementation was an independent predictor of survival (odds ratio: 0.876; 95% CI: 0.771-0.995, P = 0.04, c-statistic: 0.84). These findings suggest that regional collaboration and network-wide, uniform triage practices should be key components in the development of regionalized trauma networks.

Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study.

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) is highly effective in men who have sex with men (MSM) at the individual level, but data on population-level impact are lacking. We examined whether rapid, targeted, and high-coverage roll-out of PrEP in an MSM epidemic would reduce HIV incidence in the cohort prescribed PrEP and state-wide in Australia's most populous state, New South Wales. METHODS: The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study is an implementation cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine as HIV PrEP. We recruited high-risk gay men in a New South Wales-wide network of 21 clinics. We report protocol-specified co-primary outcomes at 12 months after recruitment of the first 3700 participants: within-cohort HIV incidence; and change in population HIV diagnoses in New South Wales between the 12-month periods before and after PrEP roll-out. The study is registered with ClinicalTrials.gov, number NCT02870790. FINDINGS: We recruited 3700 participants in the 8 months between March 1, 2016, and Oct 31, 2016. 3676 (99%) were men, 3534 (96%) identified as gay, and 149 (4%) as bisexual. Median age was 36 years (IQR 30-45 years). Overall, 3069 (83%) participants attended a visit at 12 months or later. Over 4100 person-years, two men became infected with HIV (incidence 0·048 per 100 person-years, 95% CI 0·012-0·195). Both had been non-adherent to PrEP. HIV diagnoses in MSM in New South Wales declined from 295 in the 12 months before PrEP roll-out to 221 in the 12 months after (relative risk reduction [RRR] 25·1%, 95% CI 10·5-37·4). There was a decline both in recent HIV infections (from 149 to 102, RRR 31·5%, 95% CI 11·3 to 47·3) and in other HIV diagnoses (from 146 to 119, RRR 18·5%, 95% CI -4·5 to 36·6). INTERPRETATION: PrEP implementation was associated with a rapid decline in HIV diagnoses in the state of New South Wales, which was greatest for recent infections. As part of a combination prevention approach, rapid, targeted, high-coverage PrEP implementation is effective to reduce new HIV infections at the population level. FUNDING: New South Wales Ministry of Health, Gilead Sciences.

What Will It Take to End the HIV/AIDS Epidemic? Linking the Most Disenfranchised Into Care Through Outreach.

The 2015 National HIV/AIDS Strategy renewed its goal of increasing access to care for people living with HIV/AIDS (PLWHA) and called for an increased focus on linkage to care efforts. As many PLWHA face multiple barriers to care and live on the margins of society, adoption of intensive outreach activities is necessary to engage the most disenfranchised PLWHA into care and to ultimately end the HIV epidemic. The Bay Area Network for Positive Health (BANPH), comprising 12+ agencies, established a network outreach model for our linkage-to-care project to engage the hardest-to-reach populations in the San Francisco Bay Area. During the years 2010-2013, BANPH agencies conducted street outreach, analyzed internal tracking systems to identify out-of-care individuals and individuals experiencing tenuous care, and surveyed participants using Apple iPod Touch devices. During the 3-year project, BANPH agencies engaged 602 out-of-care PLWHA and linked 440 to care. On average, outreach workers made 10 contact attempts with a client to link them to care. Sixty-three percent of participants were linked to care on an average of 56 days after initial contact. Factors, including lack of case management, lack of transportation, competing concerns, substance abuse, and HIV stigma, were significantly associated with linkage-to-care outcomes. Intensive outreach efforts could help to reduce barriers to care for hard-to-reach PLWHA, but these efforts require a tremendous amount of time and resources. A network outreach model could help facilitate sharing of limited resources and increase regional outreach capacity for linkage-to-care programs.

Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients.

The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013. The years between 2008-2009 and 2011-2013 were designated as pre- and post-NOTS, respectively. Data from 2010 was excluded as a transitional year. Two trauma centers (TCs) closed in 2010. Predetermined patient subgroups were analyzed. A total of 27,843 patients were examined. Mean age was 46 and 64 per cent were male. Median Injury Severity Score (ISS) was five, and 87 per cent sustained blunt injuries. Of these, 10,641 patients were pre-NOTS and 17,202 were post-NOTS. Comparing the two groups, mortality decreased from 5 to 4 per cent post-NOTS (P < 0.001); median time to definitive care increased by 12 minutes post-NOTS. Multivariate logistic regression showed that NOTS implementation was an independent predictor for survival (P = 0.008), whereas time to definitive care was not. Subgroup analyses demonstrated mortality reductions post-NOTS for all subgroups except patients with penetrating injuries, where mortality remained the same despite an increase in ISS. Patients with ISS ≥15 had a 23 per cent relative reduction in mortality, and their median time to definitive care decreased by 12 minutes. Implementation of a collaborative, regional trauma system was associated with mortality reduction and shortened time to definitive care in the severely injured patients. These findings highlight the importance of collaboration in the future development of regional trauma systems.

Trauma system regionalization improves mortality in patients requiring trauma laparotomy.

INTRODUCTION: This study evaluates the impact of a regional trauma network (RTN) on patient survival, intensive care unit (ICU) length of stay, and hospital length of stay in patients who required trauma laparotomy. METHODS: Patients who required trauma laparotomy from January 2008 to December 2013 were analyzed. Patients admitted during 2008-2009 and 2011-2013 were designated as pre-RTN and RTN groups, respectively. The primary outcome was mortality. RESULTS: A total of 569 patients were analyzed, 231 patients were pre-RTN, and 338 were in the RTN group. Overall, mean age was 35.7 ± 17.1 and median Injury Severity Score was 16 (25th-75th percentile: 9-26). The two groups were similar with regard to age, Injury Severity Score, Abbreviated Injury Scale abdomen, sex, and mechanism. Overall, there was a 35% relative reduction in mortality from the pre-RTN to RTN group (p = 0.035), and 30% more patients were triaged to a Level 1 trauma center in the RTN group (p < 0.001). Logistic regression showed that being in the RTN group was an independent predictor for survival (p = 0.026) with odds ratio of 0.53 (95% confidence interval, 0.30-0.93). Patients with penetrating trauma had a nonsignificant decrease in mortality and a reduction of 1 day of ICU stay (p = 0.001). Patients with blunt trauma had a significant reduction in mortality from 38% in the pre-RTN group to 23% in the RTN group (p = 0.017). CONCLUSION: This study focused on the unique patient population that required trauma laparotomies. It showed that trauma system regionalization led to a significant increase in the number of patients triaged to a Level 1 trauma center and reduction of ICU length of stay. More importantly, it demonstrated the benefit of regionalization by showing a significant reduction of hospital mortality in this critically injured patient population. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Latest review shows rise in calls related to nursing practice standards.

Questions and concerns related to nursing practice standards increased to 28 percent from 18 percent of all consultations in the latest review of consultations by the College and Association of Registered Nurses of Alberta (CARNA). Consultations were initiated by phone, e-mail, fax or in person by registered nurses (RNs), employers or others who sought assistance with issues that directly or indirectly affected the delivery of safe, competent and ethical nursing care. Increases were also noted in the categories related to health-care reform and scope of practice, showing an increase to 12 percent from seven and to 17 percent from 15 respectively. These increases were offset by a decrease in calls related to legal/ethical issues to six percent of all calls from 22 percent in the previous review period.

Performance of a regional trauma network: A state-wide analysis.

BACKGROUND: The Northern Ohio Trauma System (NOTS), established in 2010, is a collaborative regional trauma system composed of one level I and several lower-level trauma centers (TCs) across multiple hospital systems. Mortalities between counties in NOTS and other Ohio counties were compared to assess NOTS performance. METHODS: State trauma registry was analyzed for patients 15 years or older from 2006 to 2012. Mortality change over time was assessed by comparing all counties before and after NOTS establishment. Two analyses were done in the post-NOTS period: (1) a county analysis, comparing Cuyahoga County, the county containing NOTS level I TC (L1TC), with other counties containing L1TCs and (2) a regional analysis, comparing Cuyahoga and its adjacent counties (i.e., the NOTS region) with other L1TC containing regions. The following subgroups were included a priori: Injury Severity Score 15 or greater, age 65 years or older, and trauma mechanism. RESULTS: A total of 178,143 patients were analyzed. Cuyahoga was the only county that had a decrease in mortality for both the overall group and all subgroups over time (all p < 0.05). Both the county and regional analyses showed that the overall NOTS patients were 1 to 4 years older (p < 0.05), had similar or higher Injury Severity Score (p < 0.05), and were treated more often at lower-level TCs (p < 0.001). County analysis demonstrated that Cuyahoga County had approximately 1% lower mortality in geriatrics patients compared with non-NOTS counties. Regional analysis showed lower mortality in the NOTS region for the overall patient group, as well as geriatric and blunt injuries subgroups. CONCLUSIONS: Cuyahoga was the only county in Ohio that had significant mortality reduction for all patient groups over time. Trauma system regionalization was associated with greater utilization of lower-level TCs and lower patient mortality. These findings suggest that a collaborative regional trauma system may be more important than the number of L1TC in an area. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Implementation of an image sharing system significantly reduced repeat computed tomographic imaging in a regional trauma system.

BACKGROUND: The practice of repeating computed tomography (re-CT) is common among trauma patients transferred between hospitals incurring additional cost and radiation exposure. This study sought to evaluate the effectiveness of implementing modern cloud-based technology (lifeIMAGE) across a regional trauma system to reduce the incidence of re-CT imaging. METHODS: This is a prospective interventional study to evaluate outcomes after implementation of lifeIMAGE in January 2012. Key outcomes were rates of CT imaging, including the rates and costs of re-CT from January 2009 through December 2012. RESULTS: There were 1,081 trauma patients transferred from participating hospitals during the study period (657 patients before and 425 patients after implementation), with the overall re-CT rate of 20.5%. Rates of any CT imaging at referring hospitals decreased (62% vs. 55%, p < 0.05) and also decreased at the accepting regional Level I center (58% vs. 52%, p < 0.05) following system implementation. There were 639 patients (59%) who had CT imaging performed before transfer (404 patients before and 235 patients after implementation). Of these patients, the overall re-CT rate decreased from 38.4% to 28.1% (p = 0.01). Rates of re-CT of the head (21% vs. 11%, p = 0.002), chest (7% vs. 3%, p = 0.05), as well as abdomen and pelvis (12% vs. 5%, p = 0.007) were significantly reduced following system implementation. The cost of repeat imaging per patient was significantly lower following system implementation (mean charges, $1,046 vs. $589; p < 0.001). These results were more pronounced in a subgroup of patients with an Injury Severity Score (ISS) of greater than 14, with a reduction in overall re-CT rate from 51% to 30% (p = 0.03). CONCLUSION: The implementation of modern cloud-based technology across the regional trauma system resulted in significant reductions in re-CT imaging and cost. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV; economic analysis, level IV.

The use of failure mode and effect analysis in a radiation oncology setting: the Cancer Treatment Centers of America experience.

Delivering radiation therapy in an oncology setting is a high-risk process where system failures are more likely to occur because of increasing utilization, complexity, and sophistication of the equipment and related processes. Healthcare failure mode and effect analysis (FMEA) is a method used to proactively detect risks to the patient in a particular healthcare process and correct potential errors before adverse events occur. FMEA is a systematic, multidisciplinary team-based approach to error prevention and enhancing patient safety. We describe our experience of using FMEA as a prospective risk-management technique in radiation oncology at a national network of oncology hospitals in the United States, capitalizing not only on the use of a team-based tool but also creating momentum across a network of collaborative facilities seeking to learn from and share best practices with each other. The major steps of our analysis across 4 sites and collectively were: choosing the process and subprocesses to be studied, assembling a multidisciplinary team at each site responsible for conducting the hazard analysis, and developing and implementing actions related to our findings. We identified 5 areas of performance improvement for which risk-reducing actions were successfully implemented across our enterprise.