Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America.

Importance: Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. Objective: To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). Design, Setting, and Participants: This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. Exposures: People experiencing homelessness were identified using the TQP's alternate home residence variable. Main Outcomes and Measures: Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Results: Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). Conclusions and Relevance: The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.

Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness.

Importance: Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale. Objective: To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission. Design, Setting, and Participants: This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022. Exposures: PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable. Main Outcomes and Measures: The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment). Results: A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19). Conclusions and Relevance: Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.

Hospital variability in adoption of alcohol and drug screening in adult trauma patients.

BACKGROUND: Despite recommendations to screen all injured patients for substance use, single-center studies have reported underscreening. This study sought to determine if there was significant practice variability in adoption of alcohol and drug screening of injured patients among hospitals participating in the Trauma Quality Improvement Program. METHODS: This was a retrospective observational cross-sectional study of trauma patients 18 years or older in Trauma Quality Improvement Program 2017-2018. Hierarchical multivariable logistic regression modeled the odds of screening for alcohol and drugs via blood/urine test while controlling for patient and hospital variables. We identified statistically significant high and low-screening hospitals based on hospitals' estimated random intercepts and associated confidence intervals (CIs). RESULTS: Of 1,282,111 patients at 744 hospitals, 619,423 (48.3%) were screened for alcohol, and 388,732 (30.3%) were screened for drugs. Hospital-level alcohol screening rates ranged from 0.8% to 99.7%, with a mean rate of 42.4% (SD, 25.1%). Hospital-level drug screening rates ranged from 0.2% to 99.9% (mean, 27.1%; SD, 20.2%). A total of 37.1% (95% CI, 34.7-39.6%) of variance in alcohol screening and 31.5% (95% CI, 29.2-33.9%) of variance in drug screening were at the hospital level. Level I/II trauma centers had higher adjusted odds of alcohol screening (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.41) and drug screening (aOR, 1.16; 95% CI, 1.08-1.25) than Level III and nontrauma centers. We found 297 low-screening and 307 high-screening hospitals in alcohol after adjusting for patient and hospital variables. There were 298 low-screening and 298 high-screening hospitals for drugs. CONCLUSION: Overall rates of recommended alcohol and drug screening of injured patients were low and varied significantly between hospitals. These results underscore an important opportunity to improve the care of injured patients and reduce rates of substance use and trauma recidivism. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

The Structural Violence Trap: Disparities in Homicide, Chronic Disease Death, and Social Factors Across San Francisco Neighborhoods.

BACKGROUND: On average, a person living in San Francisco can expect to live 83 years. This number conceals significant variation by sex, race, and place of residence. We examined deaths and area-based social factors by San Francisco neighborhood, hypothesizing that socially disadvantaged neighborhoods shoulder a disproportionate mortality burden across generations, especially deaths attributable to violence and chronic disease. These data will inform targeted interventions and guide further research into effective solutions for San Francisco's marginalized communities. STUDY DESIGN: The San Francisco Department of Public Health provided data for the 2010-2014 top 20 causes of premature death by San Francisco neighborhood. Population-level demographic data were obtained from the US American Community Survey 2015 5-year estimate (2011-2015). The primary outcome was the association between years of life loss (YLL) and adjusted years of life lost (AYLL) for the top 20 causes of death in San Francisco and select social factors by neighborhood via linear regression analysis and heatmaps. RESULTS: The top 20 causes accounted for N = 15,687 San Francisco resident deaths from 2010-2014. Eight neighborhoods (21.0%) accounted for 47.9% of city-wide YLLs, with 6 falling below the city-wide median household income and many having a higher percent population Black, and lower education and higher unemployment levels. For chronic diseases and homicides, AYLLs increased as a neighborhood's percent Black, below poverty level, unemployment, and below high school education increased. CONCLUSIONS: Our study highlights the mortality inequity burdening socially disadvantaged San Francisco neighborhoods, which align with areas subjected to historical discriminatory policies like redlining. These data emphasize the need to address past injustices and move toward equal access to wealth and health for all San Franciscans.

Helicopter transport: help or hindrance?

PURPOSE OF REVIEW: Traumatic injury continues to be a significant cause of morbidity and mortality in the year 2011. In addition, the healthcare expenditures and lost years of productivity represent significant economic cost to the affected individuals and their communities. Helicopters have been used to transport trauma patients for the past 40 years, but there are conflicting data on the benefits of helicopter emergency medical service (HEMS) in civilian trauma systems. Debate persists regarding the mortality benefit, cost-effectiveness, and safety of helicopter usage, largely because the studies to date vary widely in design and generalizability to trauma systems serving heterogeneous populations and geography. Strict criteria should be established to determine when HEMS transport is warranted and most likely to positively affect patient outcomes. Individual trauma systems should conduct an assessment of their resources and needs in order to most effectively incorporate helicopter transport into their triage model. RECENT FINDINGS: Research suggests that HEMS improves mortality in certain subgroups of trauma patients, both after transport from the scene of injury and following interfacility transport. Studies examining the cost-effectiveness of HEMS had mixed results, but the majority found that it is a cost-effective tool. Safety remains an issue of contention with HEMS transport, as helicopters are associated with significant safety risk to the crew and patient. However, this risk may be justified provided there is a substantial mortality benefit to be gained. SUMMARY: Recent studies suggest that strict criteria should be established to determine when helicopter transport is warranted and most likely to positively affect patient outcomes. Individual trauma systems should conduct an assessment of their resources and needs in order to most effectively incorporate HEMS into their triage model. This will enable regional hospitals to determine if the costs and safety risks associated with HEMS are worthwhile given the potential benefits to patient morbidity and mortality.

Roadway features associated with elderly drivers in motor vehicle crashes.

BACKGROUND: As the number of older US drivers has increased over the past decades, so has the number of injuries, hospitalizations, and deaths from motor vehicle crashes (MVCs) involving elderly drivers. We seek to identify personal, environmental, and roadway features associated with increased crashes involving elderly drivers. We hypothesize that elderly drivers are more likely to be involved in MVCs at intersections with more complex signage and traffic flow. METHODS: This is a retrospective observational study using 2015 to 2019 police traffic crash reports and a Department of Public Health database of built-environment variables from a single urban center. Demographics and environmental/road features were compared for vehicle-only MVCs involving elderly (≥65 years) and younger drivers. χ2 and nonparametric tests were used to analyze 36,168 drivers involved in MVCs. RESULTS: There were 2,575 (7.1%) elderly drivers involved in MVCs during the study period. Left turns and all-way stop signs were associated with increased crash risk among elderly drivers compared with younger drivers. Elderly-involved MVCs were less likely to occur at intersections with left-turn restrictions, traffic lights, only one-way streets, and bike lanes compared with MVCs with younger drivers. Elderly drivers were more likely to be involved in MVCs on weekdays, less often intoxicated at the time of the crash, and less frequently involved in fatal MVCs compared with younger drivers. However, elderly drivers were more frequently the at-fault party, especially after the age of 75 years. CONCLUSION: Updates to roadway features have potential to decrease injury and death from MVCs involving elderly adults. Left turn restrictions or other innovative safety treatments at all-way stops or where left turns are permitted may mitigate road crashes involving older adults. Education may increase awareness of higher-risk driving tasks such as turning left, and driving alternatives including public transportation/paratransit may offer alternate means to maintain activities of daily living. LEVEL OF EVIDENCE: Prognostic/Epidemiological, level IV.

The DISTANCE study: Determining the impact of social distancing on trauma epidemiology during the COVID-19 epidemic-An interrupted time-series analysis.

BACKGROUND: The large-scale social distancing efforts to reduce SARS-CoV-2 transmission have dramatically changed human behaviors associated with traumatic injuries. Trauma centers have reported decreases in trauma volume, paralleled by changes in injury mechanisms. We aimed to quantify changes in trauma epidemiology at an urban Level I trauma center in a county that instituted one of the earliest shelter-in-place orders to inform trauma care during future pandemic responses. METHODS: A single-center interrupted time-series analysis was performed to identify associations of shelter-in-place with trauma volume, injury mechanisms, and patient demographics in San Francisco, California. To control for short-term trends in trauma epidemiology, weekly level data were analyzed 6 months before shelter-in-place. To control for long-term trends, monthly level data were analyzed 5 years before shelter-in-place. RESULTS: Trauma volume decreased by 50% in the week following shelter-in-place (p < 0.01), followed by a linear increase each successive week (p < 0.01). Despite this, trauma volume for each month (March-June 2020) remained lower compared with corresponding months for all previous 5 years (2015-2019). Pediatric trauma volume showed similar trends with initial decreases (p = 0.02) followed by steady increases (p = 0.05). Reductions in trauma volumes were due entirely to changes in nonviolent injury mechanisms, while violence-related injury mechanisms remained unchanged (p < 0.01). CONCLUSION: Although the shelter-in-place order was associated with an overall decline in trauma volume, violence-related injuries persisted. Delineating and addressing underlying factors driving persistent violence-related injuries during shelter-in-place orders should be a focus of public health efforts in preparation for future pandemic responses. LEVEL OF EVIDENCE: Epidemiological study, level III.

"You don't want anyone who hasn't been through anything telling you what to do, because how do they know?": Qualitative analysis of case managers in a hospital-based violence intervention program.

STATEMENT OF PURPOSE: Intentional violent injury is a leading cause of disability and death among young adults in the United States. Hospital-based violence intervention programs (HVIPs), which strive to prevent re-injury through intensive case management, have emerged as a successful and cost-effective strategy to address this issue. Despite the importance of strong therapeutic relationships between clients and their case managers, specific case manager behaviors and attributes that drive the formation of these relationships have not been elucidated. METHODS: A qualitative analysis with a modified grounded theory approach was conducted to gain insight into what clients perceive to be crucial to the formation of a strong client-case manager relationship. Twenty-four semi-structured interviews were conducted with prior clients of our hospital's HVIP. The interviews were analyzed using constant comparison method for recurrent themes. RESULTS: Several key themes emerged from the interviews. Clients emphasized that their case managers must: 1) understand and relate to their sociocultural contexts, 2) navigate the initial in-hospital meeting to successfully create connection, 3) exhibit true compassion and care, 4) serve as role models, 5) act as portals of opportunity, and 6) engender mutual respect and pride. CONCLUSIONS: This study identifies key behaviors of case managers that facilitate the formation of strong therapeutic relationships at the different stages of client recovery. This study's findings emphasize the importance of case managers being culturally aligned with and embedded in their clients' communities. This work can provide a roadmap for case managers to form optimally effective relationships with clients.

Effect of mass shootings on gun sales-A 20-year perspective.

BACKGROUND: Granular data on gun sales has been historically difficult to obtain. In 2016, California (CA) made monthly data from 1996 to 2015 publically available. Control charts are a method to analyze how a process changes over time in response to nonroutine events. We utilized this technique to study the impact of US mass shootings on CA gun sales. METHODS: Monthly gun sales were provided by the CA Department of Justice and monthly fatalities from the CDC Wonder Death Certificate Registry. Mass shooting events were obtained from after-action reports, news media, and court proceedings. Time-ordered data were analyzed with control charts with 95% confidence intervals (upper control limit, lower control limit) using QiMacros. RESULTS: Individual gun sales of 9,917,811 occurred in CA with a median monthly rate of 41,324 (range, 20,057-132,903). A median of 263 people lost their lives monthly from firearms (124 homicides, 128 suicides), totaling 53,975 fatalities from 1999 to 2015. Fifteen of 21 current deadliest mass shootings occurred during this study period with 40% from 2012 to 2015. Also, 36 school shootings occurred during the study (mean, 5 deaths; range, 0-33; 6 injuries; range, 0-23) with 31% in 2012 to 2015 at rate of 3 events/year versus 1.4 events/year in the 17 prior years (p < 0.05). Sales were generally consistent from 1996 to 2011 (except post-Columbine, Col). Starting in 2011, sales exceeded the 95% predicted upper control limit every single month. Before October 2011, there was no statistically significant sustained effect of mass shootings on sales (except Col); however, since a statistically significant proportional spike in sales occurred in the months immediately following every single deadliest mass shooting event. Every year since 2012, CA has strengthened gun laws in response to mass shootings yet sales have risen immediately preceding enactment of these laws each January. CONCLUSION: Gun sales are more frequent since 2012, with an additional increase following both mass shootings and legislative changes enacted in response to these shootings. LEVEL OF EVIDENCE: Epidemiology, level III.

Evaluating the Potential Benefits of Advanced Automatic Crash Notification.

OBJECTIVE: Advanced Automatic Collision Notification (AACN) services in passenger vehicles capture crash data during collisions that could be transferred to Emergency Medical Services (EMS) providers. This study explored how EMS response times and other crash factors impacted the odds of fatality. The goal was to determine if information transmitted by AACN could help decrease mortality by allowing EMS providers to be better prepared upon arrival at the scene of a collision. METHODS: The Crash Injury Research and Engineering Network (CIREN) database of the US Department of Transportation/National Highway Traffic Safety Administration (USDOT/NHTSA; Washington DC, USA) was searched for all fatal crashes between 1996 and 2012. The CIREN database also was searched for illustrative cases. The NHTSA's Fatal Analysis Reporting System (FARS) and National Automotive Sampling System Crashworthiness Data System (NASS CDS) databases were queried for all fatal crashes between 2000 and 2011 that involved a passenger vehicle. Detailed EMS time data were divided into prehospital time segments and analyzed descriptively as well as via multiple logistic regression models. RESULTS: The CIREN data showed that longer times from the collision to notification of EMS providers were associated with more frequent invasive interventions within the first three hours of hospital admission and more transfers from a regional hospital to a trauma center. The NASS CDS and FARS data showed that rural collisions with crash-notification times >30 minutes were more likely to be fatal than collisions with similar crash-notification times occurring in urban environments. The majority of a patient's prehospital time occurred between the arrival of EMS providers on-scene and arrival at a hospital. The need for extrication increased the on-scene time segment as well as total prehospital time. CONCLUSION: An AACN may help decrease mortality following a motor vehicle collision (MVC) by alerting EMS providers earlier and helping them discern when specialized equipment will be necessary in order to quickly extricate patients from the collision site and facilitate expeditious transfer to an appropriate hospital or trauma center. Plevin RE , Kaufman R , Fraade-Blanar L , Bulger EM . Evaluating the potential benefits of advanced automatic crash notification. Prehosp Disaster Med. 2017;32(2):156-164.

The Role of Lipopolysaccharide Structure in Monocyte Activation and Cytokine Secretion.

BACKGROUND: The lipopolysaccharide (LPS) molecule is composed of a hydrophobic lipid region (Lipid A), an oligosaccharide core, and an O-Antigen chain. Lipid A has been described as the molecular region responsible for inducing activation of immune cells. We hypothesize that the O-Antigen plays a critical role in the activation and responsiveness of mononuclear cell immune function. METHODS: Peripheral blood mononuclear cells (PBMCs) from healthy volunteers were stimulated with LPS, LPS with attenuated O-Antigen (RF5), or Lipid A (DPL), which lacks an O-Antigen. Selected cells were pretreated with a blocking antibody to CD14. Western blots were performed to determine activation of mitogen-activated protein kinases (MAPK) p38, ERK, and JNK at selected time-points. RNA was extracted for RT-PCR quantification of TNF-α and IL-10 gene transcription. Supernatants were harvested and analyzed by ELISA for tumor necrosis factor alpha (TNF-α) and interleukin 10 (IL-10). RESULTS: LPS elicited maximal response, including phosphorylation of p38, ERK, and JNK, synthesis of TNF-α and IL-10 mRNA, and secretion of TNF-α and IL-10. Stimulation with RF5 activated the same pathways to a lesser degree. DPL led to increased phosphorylation of p38 and ERK and increased secretion of IL-10. CD14 blockade was associated with a significant decrease in cytokine secretion by LPS, and abolished cytokine secretion in cells stimulated with RF5 or DPL. CONCLUSIONS: Structural variants of LPS activate monocytes differentially. The complete O-Antigen is important for maximal activation of MAPK, cytokine synthesis, and cytokine secretion. LPS with attenuated O-Antigen and Lipid A activate only certain components of these pathways. LPS with a complete O-Antigen stimulates cytokine secretion that is partially independent of CD14, but shortening or removal of the O-Antigen inhibits this secretion.