Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension.

BACKGROUND: The impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. METHODS: Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. RESULTS: A total of 430 patients were included (median age 43 years [interquartile range: 29-61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10-33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6-9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6-10] vs 7 [6-9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11-1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. CONCLUSION: Better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

A Collaborative Multidisciplinary Trauma Program Improvement Team Improves VTE Chemoprophylaxis Guideline Compliance In Non-Operative Stable TBI.

BACKGROUND: Delays in initiating venous thromboembolism (VTE) prophylaxis in patients suffering from traumatic brain injury (TBI) persist despite guidelines recommending early initiation. We hypothesized that the expansion of a Trauma Program Performance Improvement (PI) team will improve compliance of early (24-48 hour) initiation of VTE prophylaxis and will decrease VTE events in TBI patients. METHODS: We performed a single-center retrospective review of all TBI patients admitted to a Level I trauma center before (2015-2016,) and after (2019-2020,) the expansion of the Trauma Performance Improvement and Patient Safety (PIPS) team and the creation of trauma process and outcome dashboards. Exclusion criteria included discharge or death within 48 hours of admission, expanding intracranial hemorrhage on CT scan, and a neurosurgical intervention (craniotomy, pressure monitor, or drains) prior to chemoprophylaxis initiation. RESULTS: A total of 1,112 patients met the inclusion criteria, of which 54% (n = 604) were admitted after Trauma PIPS expansion. Following the addition of a dedicated PIPS nurse in the trauma program and creation of process dashboards, the time from stable CT to VTE prophylaxis initiation decreased (52 hours to 35 hours; p < 0.001) and more patients received chemoprophylaxis at 24-48 hours (59% from 36%, p < 0.001) after stable head CT. There was no significant difference in time from first head CT to stable CT (9 vs 9 hours; p = 0.15). The Contemporary group had a lower rate of VTE events (1% vs 4%; p < 0.001) with no increase in bleeding events (2% vs 2%; p = 0.97). On multivariable analysis, being in the Early cohort was an independent predictor of VTE events (aOR: 3.74; 95%CI: 1.45-6.16). CONCLUSION: A collaborative multidisciplinary Trauma PIPS team improves guideline compliance. Initiation of VTE chemoprophylaxis within 24-48 hours of stable head CT is safe and effective. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

Getting out of the bay faster: Assessing trauma team performance using trauma video review.

BACKGROUND: Minutes matter for trauma patients in hemorrhagic shock. How trauma team function impacts time to the next phase of care has not been rigorously evaluated. We hypothesized better team performance scores to be associated with decreased time to the next phase of trauma care. METHODS: This retrospective secondary analysis of a prospective multicenter observational study included hypotensive trauma patients at 19 centers. Using trauma video review, we analyzed team performance with the validated Non-Technical Skills for Trauma scale: leadership, cooperation and resource management, communication, assessment/decision making, and situational awareness. The primary outcome was minutes from patient arrival to next phase of care; deaths in the bay were excluded. Secondary outcomes included time to initiation and completion of first unit of blood and inpatient mortality. Associations between team dynamics and outcomes were assessed with a linear mixed-effects model adjusting for Injury Severity Score, mechanism, initial blood pressure and heart rate, number of team members, and trauma team lead training level and sex. RESULTS: A total of 441 patients were included. The median Injury Severity Score was 22 (interquartile range, 10-34), and most (61%) sustained blunt trauma. The median time to next phase of care was 23.5 minutes (interquartile range, 17-35 minutes). Better leadership, communication, assessment/decision making, and situational awareness scores were associated with faster times to next phase of care (all p < 0.05). Each 1-point worsening in the Non-Technical Skills for Trauma scale score (scale, 5-15) was associated with 1.6 minutes more in the bay. The median resuscitation team size was 12 (interquartile range, 10-15), and larger teams were slower ( p < 0.05). Better situational awareness was associated with faster completion of first unit of blood by 4 to 5 minutes ( p < 0.05). CONCLUSION: Better team performance is associated with faster transitions to next phase of care in hypotensive trauma patients, and larger teams are slower. Trauma team training should focus on optimizing team performance to facilitate faster hemorrhage control. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

To leave or not to leave: American Association for the Surgery of Trauma (AAST) panel discussion on personal, parental, and family leave.

Navigating planned and emergent leave during medical practice is very confusing to most physicians. This is especially challenging to the trauma and acute care surgeon, whose practice is unique due to overnight in-hospital call, alternating coverage of different services, and trauma center's staffing challenges. This is further compounded by a surgical culture that promotes the image of a 'tough' surgeon and forgoing one's personal needs on behalf of patients and colleagues. Frequently, surgeons find themselves having to make a choice at the crossroads of personal and family needs with work obligations: to leave or not to leave. Often, surgeons prioritize their professional commitment over personal wellness and family support. Extensive research has been conducted on the topic of maternity leave and inequality towards female surgeons, primarily focused on trainees. The value of paternity leave has been increasingly recognized recently. Consequently, significant policy changes have been implemented to support trainees. Practicing surgeon, however, often lack such policy support, and thus may default to local culture or contractual agreement. A panel session at the American Association for the Surgery of Trauma 2022 annual meeting was held to discuss the current status of planned or unanticipated leave for practicing surgeons. Experiences, perspectives, and propositions for change were discussed, and are presented here.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Under the Lens: Team Perception of Trauma Video Review.

BACKGROUND: Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood. OBJECTIVE: We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups. METHODS: An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem). RESULTS: We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions. CONCLUSIONS: TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.

Higher center volume is significantly associated with lower mortality in trauma patients with shock.

INTRODUCTION: Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS: We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS: Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION: After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial.

Objective: To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data: Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods: A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results: A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion: This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence: NA.

Evaluating emergency department tube thoracostomy: A single-center use of trauma video review to assess efficiency and technique.

BACKGROUND: Emergency department tube thoracostomy is a common procedure; however, assessing procedural skills is difficult. We sought to describe procedural variability and technical complications of emergency department tube thoracostomy using trauma video review. We hypothesized that factors such as hemodynamic abnormality lead to increased technical difficulty and malpositioning. METHODS: Using trauma video review, we reviewed all emergency department tube thoracostomy from 2020 to 2022. Patients were stratified into hemodynamically abnormal (systolic blood pressure <90 or heart rate >120) and hemodynamically normal (systolic blood pressure ≥90 or heart rate ≤120). Emergency department tube thoracostomies outside of video-capable rooms, with incomplete visualization, or in patients undergoing cardiopulmonary resuscitation or resuscitative thoracotomy were excluded. The primary outcome was a procedure score modified from the validated tool ranging from 0 to 11 (higher score indicating better performance). Also measured were procedural times to (1) decision to place, (2) pleural entry, and (3) procedure completion. Postprocedure x-ray and chart review were used to determine accuracy. RESULTS: In total, 51 videos met the inclusion criteria. The median age was 34 [interquartile range 24-40] years, body mass index 25.8 [interquartile range 21.8-30.7], predominately male (75%), blunt injury (57%), with Injury Severity Score of 22 [14.5-41]. The median procedure score was 9 [7-10]. Emergency department tube thoracostomies in patients with abnormal hemodynamics had significantly lower procedure scores (8 vs 10, P < .05). Hemodynamically abnormal patients had significantly shorter times from decision to proceed to pleural entry (4.05 vs 8.25 minutes, P < .001), and to completion (6.31 vs 14.23 minutes, P < .001). The most common complication was malpositioning (35.1%), with no significant difference noted when comparing hemodynamically normal and abnormal patients (P = .41). CONCLUSION: Using trauma video review we identified significant procedural variability in emergency department tube thoracostomy, mainly that hemodynamic abnormality led to lower proficiency scores and increased malpositioning. Efforts are needed to define procedural benchmarks and evaluation in the context of patient outcomes. Using this technology and methodology can help establish procedural norms.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania.

BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

Preventing the most common firearm deaths: Modifiable factors related to firearm suicide.

BACKGROUND: More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates. METHODS: We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates. RESULTS: In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (ß, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases. CONCLUSIONS: During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.

Modifiable Factors Related to Firearm Homicides: A Broader View of Our Lane.

OBJECTIVE: This study aims to identify modifiable factors related to firearm homicide (FH). SUMMARY BACKGROUND DATA: Many socioeconomic, legislative and behavioral risk factors impact FH. Most studies have evaluated these risk factors in isolation, but they coexist in a complex and ever-changing American society. We hypothesized that both restrictive firearm laws and socioeconomic support would correlate with reduced FH rates. METHODS: To perform our ecologic cross-sectional study, we queried the Centers for Disease Control (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) and Federal Bureau of Investigation (FBI) Uniform Crime Reporting (UCR) for 2013-2016 state FH data. We retrieved firearm access estimates from the RAND State-Level Firearm Ownership Database. Alcohol use and access to care data were captured from the CDC Behavioral Risk Factor Surveillance System (BRFSS). Detached youth rates, socioeconomic support data and poverty metrics were captured from US Census data for each state in each year. Firearm laws were obtained from the State Firearms Law Database. Variables with significant FH association were entered into a final multivariable panel linear regression with fixed effect for state. RESULTS: A total of 49,610 FH occurred in 2013-2016 (median FH rate: 3.9:100,000, range: 0.07-11.2). In univariate analysis, increases in concealed carry limiting laws ( P =0.012), detached youth rates ( P <0.001), socioeconomic support ( P <0.001) and poverty rates ( P <0.001) correlated with decreased FH. Higher rates of heavy drinking ( P =0.036) and the presence of stand your ground doctrines ( P =0.045) were associated with increased FH. Background checks, handgun limiting laws, and weapon access were not correlated with FH. In multivariable regression, increased access to food benefits for those in poverty [ß: -0.132, 95% confidence interval (CI): -0.182 to -0.082, P <0.001] and laws limiting concealed carry (ß: -0.543, 95% CI: -0.942 to -0.144, P =0.008) were associated with decreased FH rates. Allowance of stand your ground was associated with more FHs (ß: 1.52, 95% CI: 0.069-2.960, P <0.040). CONCLUSIONS: The causes and potential solutions to FH are complex and closely tied to public policy. Our data suggests that certain types of socioeconomic support and firearm restrictive legislation should be emphasized in efforts to reduce firearm deaths in America.

Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable.

OBJECTIVE: To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND: Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS: We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS: For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS: The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.

Coming in hot: Police transport and prehospital time after firearm injury.

BACKGROUND: In Philadelphia, PA, police and emergency medical services (EMS) transport patients with firearm injuries. Prior studies evaluating this system have lacked reliable prehospital times. By linking police and hospital data sets, we established a complete timeline from firearm injury to outcome. We hypothesized that police-transported patients have shorter prehospital times that, in turn, are associated with improved survival and increased unexpected survivorship at 6 and 24 hours. METHODS: This retrospective study linked patient-level data from OpenDataPhilly Shooting Victims and the Pennsylvania Trauma Systems Foundation. All adults transported to a Level I or II trauma center after firearm injury in Philadelphia from 2015 to 2018 were included. Patient-level characteristics were compared between cohorts; unexpected survivors were identified using Trauma Score-Injury Severity Score. Multiple regression estimated risk-adjusted associations between transport method, prehospital time, and outcomes. RESULTS: Police-transported patients (n = 977) had significantly shorter prehospital times than EMS-transported patients (n = 320) (median, 9 minutes [interquartile range, 7-12 minutes] vs. 21 minutes [interquartile range, 16-29 minutes], respectively; p < 0.001). Police-transported patients were more often severely injured than those transported by EMS (60% vs. 50%, p = 0.002). After adjusting for confounders, police-transported patients had improved survival relative to EMS on hospital arrival (87% vs. 84%, respectively, p = 0.035), but not at 6 hours (79% vs. 78%, respectively, p = 0.126) or 24 hours after arrival (76% vs. 76%, respectively, p = 0.224). Compared with EMS, police-transported patients were significantly more likely to be unexpected survivors at 6 hours (6% vs. 2%, respectively, p < 0.001) and 24 hours (3% vs. 1%, respectively, p = 0.021). CONCLUSION: Police-transported patients had more severe injuries, shorter prehospital times, and increased likelihood of unexpected survival compared with EMS-transported patients. After controlling for confounders, patient physiology and injury severity represent meaningful determinants of mortality in our mature trauma system, indicating an ongoing opportunity to optimize in-hospital care. Future studies should investigate causes of death among unexpected early survivors to mitigate preventable mortality. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.

Operative trauma volume is not related to risk-adjusted mortality rates among Pennsylvania trauma centers.

BACKGROUND: Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions. METHODS: We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models. RESULTS: We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups. CONCLUSION: In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.