Emergency Medical Service Transport Time and Trauma Outcomes at an Urban Level 1 Trauma Center: Evaluation of Prehospital Emergency Medical Service Response.

BACKGROUND: The use of helicopter emergency medical services (HEMS) for trauma patients has been debated since its introduction. We aim to compare outcomes for trauma patients transported by ground EMS (GEMS) vs. HEMS using raw and adjusted mortality in a level 1 trauma center. METHODS: A 6-year retrospective cohort study utilizing our level 1 trauma center registry for patients transferred by GEMS or HEMS was performed. Demographics and outcome measures were compared. Raw and adjusted mortality was evaluated. Adjusted mortality was determined incorporating confounders, including patient demographics, comorbid conditions, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale score, and EMS transport time. Chi-square, multivariable logistic regression, and independent sample T-test were utilized with significance, defined as P < .05. RESULTS: Of 12 633 patients, 10 656 were transported via GEMS and 1977 with HEMS. Mean age was 55 for GEMS and 40 for HEMS (P < .001). Mean ISS was 9.29 and 11.73 for GEMS and HEMS (P < .001). Mean Revised Trauma Score was higher (less severe) for GEMS vs. HEMS (7.6 vs. 7.12, P < .001). Mean transport times for GEMS and HEMS was 39.45 vs. 47.29 minutes (P = .02). Raw mortality was 2.55% (307/10 656) for GEMS and 6.78% (134/1977) for HEMS. Adjusted mortality revealed a 16.6% increased mortality for GEMS compared to HEMS (adjusted odds ratio = 1.166, 95% CI: .815-1.668). CONCLUSIONS: Air-lifted trauma patients were younger, more severely injured, and more hemodynamically unstable and required longer transport time but experienced lower adjusted mortality. Future research is needed to investigate whether reducing transport times and augmenting the advanced care already implemented by HEMS crews can improve outcomes.

A Nationwide Analysis of Popliteal Vascular Injuries and Outcomes by Hospital Teaching Status.

BACKGROUND: Popliteal artery injuries are the second most common arterial injuries below the inguinal ligament. We aimed to compare outcomes in patients with popliteal injuries by hospital teaching status utilizing the National Trauma Data Bank Research Data Set (NTDB-RDS) 2013-2016. METHODS: Four-year retrospective study using the NTDB-RDS, evaluating popliteal vascular injuries. Patients were divided by popliteal injury type and teaching status into; nonteaching hospital (NTH), community teaching (CTH), or University teaching (UTH). Demographics and outcome measures were compared between groups. Risk-adjusted mortality odds ratios (ORs) were calculated. Significance was defined as P < 0.05. RESULTS: 3,577,168 patients were in the NTDB-RDS, with 1120 having a popliteal injury, (incidence = 0.03%). There was no significant difference in the amputation rate between patients treated in NTHs, CTHs, or UTHs (P > 0.05). There was no significant difference in the raw mortality rate between patients treated in NTHs, CTHs, or UTHs. After adjusting for confounders; compared to NTH, the odds ratio for mortality for popliteal artery injuries in the CTH group was significantly higher (OR: 15.95, 95% CI: 1.19-213.84), and for the UTH group the mortality was also significantly higher (OR: 5.74, 95% CI: 0.45-72.95). CONCLUSIONS: The incidence of popliteal vascular injuries was 0.03% for 2013-2016. Patients with popliteal artery injuries treated at community teaching hospitals have a 16 times higher risk of mortality and at university teaching hospitals have a 5.7 times higher risk of mortality than patients treated at nonteaching hospitals.

Variability in Current Trauma Systems and Outcomes.

BACKGROUND: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications. STUDY DESIGN AND METHODS: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05. RESULTS: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001). CONCLUSION: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference.

Pediatric Seat Belt Use in Motor Vehicle Collisions: The Need for Driver Education Programs.

BACKGROUND: By statute, pediatric passengers transported in motor vehicles need to be appropriately restrained. The National Highway Traffic Safety Administration (NHTSA) estimates that currently only 2% of children do not wear safety restraints. This study aimed primarily to evaluate the use of pediatric restraints (seat belts) in motor vehicle collisions (MVCs) transported to our Level I pediatric trauma center (PTC) compared with historical NHTSA controls. METHODS: A 4-year review utilized our Level I PTC registry for patients younger than 16 years, involved in an MVC. Appropriate booster seat/child restraints were verified by EMS, fire rescue, and patient/family. Odds ratios were used to compare occurrences and χ for categorical values with significance defined as p <.05. RESULTS: A total of 685 pediatric patients in MVCs were admitted to our PTC during the study period. Only 39 of 685 (5.7%) pediatric patients were in restraints. Based on the NHTSA historical controls, 671 of 685 (98%) children would have been expected to be using restraints (5.7% vs. 98%, p < .01). The odds ratio of lack of use of child restraints or seat belts in pediatric trauma population was markedly higher compared with NHTSA historical controls (odds ratio 793.9, 95% confidence interval: 427.02-1475.98, p < .0001). CONCLUSION: Astonishingly low rates of child restraints and seat belt use in pediatric patients in MVCs, requiring admission to a PTC, indicate the need for better injury prevention programs, and parental or driver education on risks associated with lack of restraints.

A National Analysis of Traumatic Thoracic Aortic Repair: Does Insurance Status Matter?

BACKGROUND: Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS). METHODS: The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t-test, and analysis of variance were used with significance defined as P < .05. RESULTS: Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001). CONCLUSION: For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Disparities in Adult and Pediatric Trauma Outcomes: a Systematic Review and Meta-Analysis.

BACKGROUND: Although safeguards requiring emergency care are provided regardless of a patient's payor status, disparate outcomes have been reported in trauma populations. The purpose of this systematic review and meta-analysis was to determine whether race/ethnicity or insurance status had an effect on mortality and to systematically present the literature in the adult and pediatric trauma populations during the last decade. METHODS: An online search of PubMed, Cochrane Library, Google Scholar, and SAGE Journals was performed for publications from January 2009 to March 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used. The GRADE Working Group criteria were utilized to assess the evidence quality. A meta-analysis was conducted to compare mortality between insured/uninsured and Caucasian/non-Caucasian patients. RESULTS: Our search revealed 680 publications that qualified for evaluation. Of these, 41 were included in the final analysis. Twenty-six studies included adults only, nine studies included pediatric patients only, and six studies evaluated both. Twelve studies evaluated the effects of race/ethnicity, 18 examined insurance status, and 11 investigated both. Uninsured patients had 22% greater odds of death than insured patients (OR 1.22; CI 1.21-1.24). Non-Caucasian patients had 18% greater risk of death than Caucasian patients (OR 1.18; CI 1.17-1.20). CONCLUSION: Both the adult and pediatric trauma populations suffer outcome disparities based on race/ethnicity and insurance status. Overall, patients without insurance coverage and minority groups (i.e., non-Caucasians) had worse outcomes, as measured by odds of death and all-cause mortality.

The Impact of Geographic Distribution on Trauma Center Outcomes: Do Center Outcomes Vary by Region?

BACKGROUND: The American College of Surgeons (ACS) publishes Resources for Optimal Care of the Injured Patient (Orange Book) to provide common requirements to verify trauma centers (TCs), throughout the United States. There are very few studies that assess the impact of geography on TC outcomes. Our study aimed to evaluate the differences in geographic regions in terms of injury-adjusted all-cause mortality at ACS Level 1, 2, and 3 TCs. METHODS: Review of the 2016 Research Data Set provided by the National Trauma Data Bank. TCs were categorized by the Research Data Set into geographic regions: Northeast, Midwest, South, and West. TCs were subcategorized into ACS Level 1, 2, or 3; all others were excluded. Injury-adjusted mortality was determined using observed/expected mortality (O/E) ratios, derived from TRISS methodology. Chi-squared and t-test analyses were used with significance defined as P-value<0.05. RESULTS: Among Level 1 TCs, the West (O/E = 0.62) and South (0.61) regions had significantly higher adjusted mortality rates than the Level 1s in the Midwest (0.52) and Northeast (0.52) (P < 0.05). Among Level 2s, the West (O/E = 0.61) and South (0.55) regions had significantly higher mortality than the Level 2s in the Midwest (0.40) and Northeast (0.35) (P < 0.05). Among Level 3 TCs, the South (O/E = 0.48) and the West (0.43) had significantly higher mortality than the Midwest (0.26) and Northeast (0.22) (P < 0.05). CONCLUSIONS: In the United States, injury-adjusted all-cause mortality rates are significantly higher in the South and West regions for ACS Level 1, 2, and 3 TCs compared with the Midwest and Northeast. This geographic disparity necessitates a deeper evaluation.

Subclavian artery injury secondary to blunt trauma successfully managed by median sternotomy with supraclavicular extension: A case report and literature review.

INTRODUCTION: Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection. CASE PRESENTATION: A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery. DISCUSSION: Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status. CONCLUSION: Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries.

Self-Inflicted Gun Violence Injuries Epidemic in the United States: A Closer Look at the Nation's Well-Being.

Gun-related injuries are a hotly debated sociopolitical topic in the United States. Annually, more than 33 million Americans seek heathcare services for mental health issues. These conditions are the leading cause of combined disability and death among women and the second highest among men. Our study's main objective was to identify cases of self-inflicted penetrating firearm injuries with reported pre-existing psychiatric conditions as defined in the 2013-2016 National Trauma Data Standard. The 2013-2016 Research Data Sets (RDSs) were reviewed. Cases were identified using the ICD-9 external cause codes 955-955.4, and ICD 10th Edition Clinical Modification external cause codes X72-X74. Odds ratios were calculated, and categorical data were analyzed by using the chi-squared test, with significance defined as P < 0.05. The 2013-2016 Research Data Set consists of 3,577,168 reported cases, with 15,535 observations of self-inflicted penetrating firearms injuries. Of those patients, 18.4 per cent had major psychiatric illnesses, 7.5 per cent had alcohol use disorder, 6.4 per cent had drug use disorder, and 0.6 per cent had dementia. An upward trend in the proportion of patients with major psychiatric illnesses was observed, from 15.5 per cent in 2013 to 18.6 per cent in 2016, peaking in 2015 at 20.9 per cent. Nearly one in three self-inflicted penetrating firearm injuries in the United States is associated with pre-existing behavioral health conditions. Advances in understanding the behavioral and social determinants leading to these conditions, and strategies to improve the diagnosis of mental illness and access to mental health care are required.

Factors Affecting Research Productivity of Trauma Surgeons.

This study aimed to identify factors that promote and impede research participation and productivity by Eastern Association for the Surgery of Trauma (EAST) surgeons. In addition, the study aimed to determine what changes can be implemented by surgical departments to improve this research productivity and granting. A 25-question anonymous research survey tool was offered to EAST surgeons. The questions analyzed factors including demographics, career accomplishments, current institution type, educational/research background, perceived barriers to research, and current research productivity, including grants. Chi-square tests were used to analyze significance at P < 0.05. The overall response rate was 26.2 per cent (445/1699). Most respondents reported not having any protected research time (86.3%), and no research resources were provided by their institution (78.7%). Factors that were significantly associated with greater research productivity included protected research time (P < 0.0001), having a mentor (P < 0.001), practicing in a university-affiliated hospital (P < 0.0001), publication(s) before completing residency training (P = 0.02), having institutional resources dedicated to research (P = 0.015), and male gender (P = 0.003). Age, race, marital status, and additional educational qualifications were not associated with statistically significant differences in research productivity in this study (P > 0.05). EAST surgeons are more likely to have scholarly productivity if they are supported with protected time, mentors, nonclinical staff dedicated to research, a history of research before completion of residency, and research resources from their institution. Barriers to research productivity include lack of institutional support, lack of protected research time, and increased regulatory policies.

Elderly Patients With Isolated Hip Fracture Requiring Surgical Intervention: Does Admitting Service Matter?

The American College of Surgeons requires trauma centers to track the number of injured patients admitted to a surgical service as well as nonsurgical admissions (NSAs) as a quality marker. We aim to compare the relationship between admitting service and outcomes in patients with isolated hip fracture (IHF). A 4-year retrospective cohort review of data collected from a single institution's trauma registry for adult patients with IHF was done. Patients were stratified into 2 groups based on admission to a surgical service versus NSA. Demographic and outcome variables including age, gender, Injury Severity Score (ISS), intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), and mortality rates were compared. Analysis of variance and χ test were used for data analysis with statistical significance defined as p < .05. A total of 629 patients with IHF were admitted. Of those, 30 (4.8%) were admitted to a surgical service and 599 (95.2%) were NSAs. Patients admitted to a surgical service were younger but average ISS was similar in both groups. Those admitted to a surgical service had a significantly shorter ICU-LOS than NSA patients (2.97 days vs. 4.91, p < .001). Readmission rate at 30 days (3.3% vs. 1.2%, p > .05) and DVT rates (0% vs. 0.4%, p > .05) were similar between groups. Mortality rates did not differ between groups (3.3% vs. 2.2%, p > .05). Patients with hip fracture requiring surgical intervention admitted to a trauma service have a shorter ICU-LOS than those admitted to nonsurgical services. Other quality markers were similar.

Disparities in National Institute of Health trauma research funding: The search for sufficient funding opportunities.

To evaluate disparities in the National Institute of Health (NIH) trauma research funding.Traumatic injury has increased in both prevalence and cost over the last decade. In the event of a traumatic injury, patients in the United States (US) rely on the trauma system to provide high-quality care. The current trauma research funding is not commensurate with the extent of the burden of trauma on the US population.In this qualitative study, the National Institutes of Health's Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) data were reviewed. The burden of traumatic injury on the US and the NIH trauma research funding was examined and compared with other diseases.In 2018, the NIH funded an estimated $639 million to traumatic injury research projects, <2% of the NIH budget. Comparatively, the NIH funded an estimated $6.3 billion towards cancer research in 2018. Cancer research receives extensively more funding than trauma research despite that trauma accounts for 24.1% of all years of potential life lost (YPLL) before age 75 compared with 21.3% for cancer.In the event of traumatic injury, trauma systems in the US should be able to provide high-quality care to patients yet cannot do so without adequate research funding. The federal funding contributed towards trauma research deserves a re-evaluation.

Thoracic Endovascular Aortic Repair Versus Open Repair: Analysis of the National Trauma Data Bank.

BACKGROUND: Blunt thoracic aortic injuries (BTAIs) carry a substantial mortality rate. Our study aimed to compare the outcomes of thoracic endovascular aortic repair (TEVAR) with open repair from trauma centers across the United States using the National Trauma Data Bank-Research Data Set (RDS). MATERIALS AND METHODS: The National Trauma Data Bank-RDS was reviewed for thoracic aortic injures and repair methods. Patients were divided into two groups: TEVAR versus open repair. Demographics and outcomes were compared between groups. Mortality rate was adjusted using the observed/expected mortality (O/E), with TRISS methodology by using the Revised Trauma Score with the Injury Severity Score. Chi-square test and t-test were used with significance defined as P < 0.05. RESULTS: Within the 2016 RDS, there were 275 cases that underwent operative repair for BTAI. Of the 275 operative cases, 62.5% (172/275) had TEVAR and 37.5% (103/275) underwent open repair. Mean age in TEVAR group was 41 and open repair group was 36 (P > 0.05). Mean Injury Severity Score for TEVAR was 36 versus 35 for open repair (P > 0.05). Mean Revised Trauma Score was 6.7 in TEVAR versus 5.5 in open group (P > 0.05). TEVAR patients had significantly lower crude mortality rate versus open repair (11% versus 25.2%, P < 0.005). When adjusted using O/E, the TEVAR group also had significantly less deaths versus open repair (0.40 versus 0.68, P < 0.000008). CONCLUSIONS: For BTAIs, thoracic endovascular aortic repairs were superior to open repair on injury-adjusted, all-cause mortality.