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Syamal S, Tran AH, Huang CC, Badrinathan A, Bassiri A, Ho VP, Towe CW. Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database. Am Surg 2024; 90:1037-1044. [PMID: 38085592 DOI: 10.1177/00031348231220597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes. METHODS A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed. RESULTS In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality. DISCUSSION Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.
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Affiliation(s)
- Sujata Syamal
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Andrew H Tran
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
| | - Chi-Ching Huang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH, USA
- Trauma Recovery Center, Institute for H.O.P.E, The MetroHealth System, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Wend CM, Fransman RB, Haut ER. Prehospital Trauma Care. Surg Clin North Am 2024; 104:267-277. [PMID: 38453301 DOI: 10.1016/j.suc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.
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Affiliation(s)
- Christopher M Wend
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA
| | - Ryan B Fransman
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303, USA
| | - Elliott R Haut
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street Suite 6-100, Baltimore, MD 21287, USA; Department of Surgery, Division of Acute Care Surgery, Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans Street, Baltimore, MD 21287, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Atkins K, Schneider A, Gallaher J, Charles A. The effect of transport mode on mortality following isolated penetrating torso Trauma. Am J Surg 2023; 226:542-547. [PMID: 37453802 PMCID: PMC10528673 DOI: 10.1016/j.amjsurg.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Prehospital interventions may increase the time to definitive care. Compared to ground ambulance, we hypothesize improved mortality for patients with isolated, penetrating torso injuries transported via private vehicle. METHODS We reviewed the National Trauma Data Bank (2017-2021) for adults with isolated, penetrating torso injuries stratified by mechanism (stabbing vs. firearm) and transport mode (private vehicle vs. ground ambulance). We performed a multivariable logistic regression to estimate the effect of transport mode on mortality. RESULTS 48,444 patients met our inclusion criteria. Patients transported by ambulance, injured by stabbing (n = 26,633) and by firearm (n = 21,811) had adjusted odds ratios of 1.81 (95%CI 1.05-3.14, p = 0.03) and 1.66 (95%CI 1.32-2.09,p < 0.001) respectively for mortality compared to private vehicle transport. CONCLUSION Patients with penetrating torso injuries have nearly twice the odds of mortality when transported by ground ambulance than private vehicles, despite injury severity. The "scoop and run" strategy may confer a survival benefit in this population.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Jared Gallaher
- Department of Surgery, University of North Carolina at Chapel Hill, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, United States.
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Renberg M, Dahlberg M, Gellerfors M, Rostami A, Günther M, Rostami E. Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business? Scand J Trauma Resusc Emerg Med 2023; 31:45. [PMID: 37684674 PMCID: PMC10492387 DOI: 10.1186/s13049-023-01112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome. METHOD This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality. RESULT A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS. CONCLUSION Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.
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Affiliation(s)
- Mattias Renberg
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Surgery, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Gellerfors
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Rapid Response Car, Capio, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Swedish Air Ambulance (SLA), Mora, Sweden
| | - Amir Rostami
- Department for Social Work and Criminology, University of Gävle, Gävle, Sweden
| | - Mattias Günther
- Department of Anesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden.
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Clinical Science and Education, Section for Anesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
| | - Elham Rostami
- Experimental Traumatology Unit, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital , Uppsala, Sweden
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McGuire SS, Keim A, Blakeney CA, Brand SI, Klassen AB, Luke A, Maher SA, Wood JM, Sztajnkrycer MD. Immediate Medical Care Rendered by US Law Enforcement Officers after Officer-Involved Shootings - An Open-Access Public Domain Video Analysis. Prehosp Disaster Med 2023; 38:168-173. [PMID: 36872570 DOI: 10.1017/s1049023x23000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND After officer-involved shootings (OIS), rapid delivery of emergency medical care is critical but may be delayed due to scene safety concerns. The purpose of this study was to describe medical care rendered by law enforcement officers (LEOs) after lethal force incidents. METHODS Retrospective analysis of open-source video footage of OIS occurring from February 15, 2013 through December 31, 2020. Frequency and nature of care provided, time until LEO and Emergency Medical Services (EMS) care, and mortality outcomes were evaluated. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS Three hundred forty-two (342) videos were included in the final analysis; LEOs rendered care in 172 (50.3%) incidents. Average elapsed time from time-of-injury (TOI) to LEO-provided care was 155.8 (SD = 198.8) seconds. Hemorrhage control was the most common intervention performed. An average of 214.2 seconds elapsed between LEO care and EMS arrival. No mortality difference was identified between LEO versus EMS care (P = .1631). Subjects with truncal wounds were more likely to die than those with extremity wounds (P < .00001). CONCLUSIONS It was found that LEOs rendered medical care in one-half of all OIS incidents, initiating care on average 3.5 minutes prior to EMS arrival. Although no significant mortality difference was noted for LEO versus EMS care, this finding must be interpreted cautiously, as specific interventions, such as extremity hemorrhage control, may have impacted select patients. Future studies are needed to determine optimal LEO care for these patients.
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Affiliation(s)
- Sarayna S McGuire
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
| | - Audrey Keim
- Mayo Clinic Alix School of Medicine, Scottsdale, ArizonaUSA
| | - Craig A Blakeney
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
| | - Shari I Brand
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, ArizonaUSA
| | - Aaron B Klassen
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
| | - Anuradha Luke
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
| | - Steven A Maher
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, ArizonaUSA
| | - Jeffrey M Wood
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
| | - Matthew D Sztajnkrycer
- Division of Prehospital Care, Department of Emergency Medicine, Mayo Clinic, Rochester, MinnesotaUSA
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Mooney CM, Banks K, Borthwell R, Victorino K, Coutu S, Browder TD, Victorino GP. Shift in Pre-Hospital Mode of Transportation for Trauma Patients during the COVID-19 Pandemic. J Surg Res 2023; 289:16-21. [PMID: 37075606 PMCID: PMC9943740 DOI: 10.1016/j.jss.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 01/10/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
Abstract
Background Since the start of the COVID-19 pandemic, we experienced alterations to modes of transportation amongst trauma patients suffering penetrating injuries. Historically, a small percentage of our penetrating trauma patients use private means of pre-hospital transportation. Our hypothesis was that the use of private transportation among trauma patients increased during the COVID-19 pandemic and was associated with better outcomes. Methods We retrospectively reviewed all adult trauma patients (Jan. 1, 2017 to Mar. 19, 2021), using the date of the shelter-in-place ordinance (Mar. 19, 2020) to separate trauma patients into pre-pandemic and pandemic patient groups. Patient demographics, mechanism of injury, mode of pre-hospital transportation, and variables such as initial ISS, Intensive Care Unit (ICU) admission, ICU length of stay (LOS), mechanical ventilator days, and mortality were recorded. Results We identified 11,919 adult trauma patients, 9,017 (75.7%) in the pre-pandemic group and 2,902 (24.3%) in the pandemic group. The number of patients using private pre-hospital transportation also increased (from 2.4% to 6.7%, p<0.001). Between the pre-pandemic and pandemic private transportation cohorts, there were reductions in mean ISS (from 8.1 ±10.4 to 5.3 ±6.6: p=0.02), ICU admission rates (from 15% to 2.4%: p<0.001) and hospital LOS (from 4.0 ±5.3 to 2.3 ±1.9: p=0.02). However, there was no difference in mortality (4.1% and 2.0%, p=0.221). Conclusion We found that there was a significant shift in pre-hospital transportation among trauma patients toward private transportation after the shelter-in-place order. However, this did not coincide with a change in mortality despite a downward trend. This phenomenon could help direct future policy and protocols in trauma systems when battling major public health emergencies.
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Affiliation(s)
- Colin M Mooney
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA,Corresponding Author: Colin Mooney, MD, Department of Surgery, UCSF- East Bay, 1411 E 31st St Oakland, CA 94602 USA C +1 (510) 266 2053, W +1 (510) 437 4267
| | - Kian Banks
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA
| | - Rachel Borthwell
- Department of Surgery, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Kealia Victorino
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA
| | - Sophia Coutu
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA
| | - Timothy D Browder
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA, 94602, USA
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7
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Stausberg T, Ahnert T, Thouet B, Lefering R, Böhmer A, Brockamp T, Wafaisade A, Fröhlich M. Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed. Eur J Trauma Emerg Surg 2022; 48:4623-4630. [PMID: 35551425 PMCID: PMC9712316 DOI: 10.1007/s00068-022-01988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI. METHODS The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information. RESULTS In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently. CONCLUSION Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.
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Affiliation(s)
- Timo Stausberg
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany.
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Ben Thouet
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Thomas Brockamp
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr.200, 51109, Cologne, Germany
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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Sakran JV, Lunardi N. Reducing Firearm Injury and Death in the United States. Adv Surg 2022; 56:49-67. [PMID: 36096577 DOI: 10.1016/j.yasu.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Firearms injury is a major cause of American morbidity and mortality. Although the firearm is a common vector, the intentions with which it is used represent a wide array of social ills-suicide, community violence, domestic violence, mass shootings, legal intervention, and unintended injury. The political and social underpinnings of this epidemic are inseparable from its prevention measures. Surgeons have an important role in firearm policy, research, prehospital and hospital advances, trauma survivor networks, and hospital-based violence prevention programs. It is only through interdisciplinary, multilevel, evidence-based prevention measures that the tides will turn on American firearm injury.
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Affiliation(s)
- Joseph V Sakran
- Emergency General Surgery, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower / Suite 6107B, Baltimore, MD 21287, USA.
| | - Nicole Lunardi
- Department of Surgery, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9159, USA
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Razzak JA, Bhatti J, Wright K, Nyirenda M, Tahir MR, Hyder AA. Improvement in trauma care for road traffic injuries: an assessment of the effect on mortality in low-income and middle-income countries. Lancet 2022; 400:329-336. [PMID: 35779549 DOI: 10.1016/s0140-6736(22)00887-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 02/18/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Abstract
Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.
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Affiliation(s)
- Junaid A Razzak
- Weill Cornell Medical Centre, New York, NY, USA; College of Medicine, Aga Khan University, Karachi Pakistan.
| | | | - Kate Wright
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MA, USA
| | - Mulinda Nyirenda
- College of Medicine, University of Malawi, Blantyre, Malawi; Ministry of Health, Blantyre, Malawi
| | | | - Adnan A Hyder
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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Glatts J, Weissenburger J, Mullen-Fortino M, Mazzone L, Cacchione PZ. Patient Extrication Process for Urban Emergency Departments. J Emerg Nurs 2022; 48:328-338. [DOI: 10.1016/j.jen.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/15/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
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Abou Arbid SA, Bachir RH, El Sayed MJ. Association between Mode of Transportation and Survival in Adult Trauma Patients with Penetrating Injuries: Matched Cohort Study between Police and Ground Ambulance Transport. Prehosp Disaster Med 2022; 37:1-8. [PMID: 35256031 DOI: 10.1017/s1049023x22000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Police transport (PT) of penetrating trauma patients has the potential to improve survival rates. There are no well-established guidelines for PT of penetrating trauma patients. STUDY OBJECTIVE This study examines the association between survival rate to hospital discharge of adult penetrating trauma patients and mode of transport (PT versus ground ambulance [GA]). METHODS A retrospective, matched cohort study was conducted using the United States (US) National Trauma Data Bank (NTDB). All adult penetrating injury patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by GA for analysis. Descriptive analysis was carried out. The patients' demographic and clinical characteristics were tabulated and stratified by the transport mode. RESULTS Out of the 733 patients with penetrating injuries, ground Emergency Medical Services (EMS) transported 513 patients and police transported 220 patients. Most patients were 16-64 years of age with a male (95.6%) and Black/African American race (79.0%) predominance. Firearm-related injuries (68.8%) were the most common mechanism of injury with the majority of injuries involving the body extremities (62.9%). Open wounds were the most common nature of injury (75.7%). The overall survival rate to hospital discharge was similar for patients transported by GA and by police (94.5% versus 92.7%; P = .343). CONCLUSION In this study, patients with penetrating trauma transported by police had similar outcomes to those transported by GA. As such, PT in penetrating trauma appears to be effective. Detailed protocols should be developed to further improve resource utilization and outcomes.
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Affiliation(s)
- Samer A Abou Arbid
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana H Bachir
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen J El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Emergency Medical Services and Prehospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon
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Okereke IC, Zahoor U, Ramadan O. Trauma Care in Nigeria: Time for an Integrated Trauma System. Cureus 2022; 14:e20880. [PMID: 35004074 PMCID: PMC8721441 DOI: 10.7759/cureus.20880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2022] [Indexed: 11/05/2022] Open
Abstract
Traumatic injuries are a global health problem. Most first world countries have developed comprehensive trauma systems to provide optimal care for injured patients. A trauma system is a coordinated effort in a defined geographic area that attempts to deliver trauma care to all injured patients and is usually integrated with the local public health system. The majority of low and middle income countries (LMIC) do not have functional trauma systems. This study aims to critique the status of trauma care in Nigeria and make a case for a re-organisation towards an inclusive trauma system. The methodology was a review of published articles and available grey literature to assess current practices in Nigeria within the various components of a trauma system, viz., injury prevention, pre-hospital care, acute care, and rehabilitation. The conclusions from this review suggest that integrating existing major trauma centres (MTCs) with smaller local hospitals within a region into an inclusive, interconnected region-based trauma system is the cheapest and most efficient way to improve Nigeria's trauma care and significantly reduce trauma mortality rates.
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Bou Saba G, Bachir R, El Sayed M. Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States. PREHOSP EMERG CARE 2021; 26:582-589. [PMID: 34550042 DOI: 10.1080/10903127.2021.1983092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.
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Affiliation(s)
- Ghassan Bou Saba
- Received June 9, 2021 from Faculty of Medicine, American University of Beirut, Beirut, Lebanon (GBS); Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon (RB, MES); Emergency Medical Services and Pre-hospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon (MES). Revised received September 14, 2021; accepted for publication September 15, 2021
| | - Rana Bachir
- Received June 9, 2021 from Faculty of Medicine, American University of Beirut, Beirut, Lebanon (GBS); Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon (RB, MES); Emergency Medical Services and Pre-hospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon (MES). Revised received September 14, 2021; accepted for publication September 15, 2021
| | - Mazen El Sayed
- Received June 9, 2021 from Faculty of Medicine, American University of Beirut, Beirut, Lebanon (GBS); Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon (RB, MES); Emergency Medical Services and Pre-hospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon (MES). Revised received September 14, 2021; accepted for publication September 15, 2021
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Maher Z, Beard JH, Dauer E, Carroll M, Forman S, Topper GV, Pathak A, Santora TA, Sjoholm LO, Zhao H, Goldberg AJ. Police transport of firearm-injured patients-more often and more injured. J Trauma Acute Care Surg 2021; 91:164-170. [PMID: 34108420 DOI: 10.1097/ta.0000000000003225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured. METHODS We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression. RESULTS Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients. CONCLUSION Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Zoё Maher
- From the Division of Trauma and Critical Care, Department of Surgery, (Z.M., J.H.B., E.D., A.P., T.A.S., L.O.S., A.J.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgery (M.C.), Yale School of Medicine, New Haven, Connecticut; Lewis Katz School of Medicine at Temple University (S.F., G.V.T.), Philadelphia, Pennsylvania, and Department of Clinical Sciences (H.Z.), Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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Taghavi S, Maher Z, Goldberg AJ, Chang G, Mendiola M, Anderson C, Ninokawa S, Tatebe LC, Maluso P, Raza S, Keating JJ, Burruss S, Reeves M, Coleman LE, Shatz DV, Goldenberg-Sandau A, Bhupathi A, Spalding MC, LaRiccia A, Bird E, Noorbakhsh MR, Babowice J, Nelson MC, Jacobson LE, Williams J, Vella M, Dellonte K, Hayward TZ, Holler E, Lieser MJ, Berne JD, Mederos DR, Askari R, Okafor BU, Haut ER, Etchill EW, Fang R, Roche SL, Whittenburg L, Bernard AC, Haan JM, Lightwine KL, Norwood SH, Murry J, Gamber MA, Carrick MM, Bugaev N, Tatar A, Duchesne J, Tatum D. An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg 2021; 91:130-140. [PMID: 33675330 PMCID: PMC8216597 DOI: 10.1097/ta.0000000000003151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/01/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE Prognostic, level III.
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16
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Jacoby SF, Branas CC, Holena DN, Kaufman EJ. Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma. Trauma Surg Acute Care Open 2020; 5:e000541. [PMID: 33305004 PMCID: PMC7692989 DOI: 10.1136/tsaco-2020-000541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/28/2020] [Accepted: 10/25/2020] [Indexed: 11/15/2022] Open
Abstract
Background Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders. Methods This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice. Results Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow. Conclusions Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency. Level of evidence Epidemiological study, level III.
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Affiliation(s)
- Sara F Jacoby
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Charles C Branas
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Daniel N Holena
- Division of Trauma, Surgical Critical Care and Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elinore J Kaufman
- Division of Trauma, Surgical Critical Care and Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Factors Associated with Survival in Adult Trauma Patients Transported to US Trauma Centers by Police. Prehosp Disaster Med 2020; 36:58-66. [PMID: 33138881 DOI: 10.1017/s1049023x20001314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Police units often reach the trauma scene before Emergency Medical Services (EMS). Initiatives aiming at delivering early basic trauma care by non-medical providers including police personnel are on the rise. This study describes characteristics of trauma patients transported by police to US hospitals and identifies factors associated with survival in this patient population. METHODS Using the 2015 National Trauma Data Bank (NTDB), an observational study was conducted of adult trauma patients who were transported by police. After describing the study population, the factors associated with survival to hospital discharge were evaluated using a multivariate analysis. RESULTS A total of 2,394 patients were included in the study. Patients had a median age of 34.0 years (interquartile range [IQR]: 25-48) and most were males (84.5%). Blunt trauma mechanism (59.4%) was more common than penetrating trauma (29.4%). Factors associated with improved survival included: comorbidity (odds ratio [OR] = 2.92; 95% CI, 1.33-6.40); use of drugs (OR = 2.91; 95% CI, 1.07-7.92); cut/pierce (OR = 11.07; 95% CI, 2.10-58.43); motor vehicle traffic (MVT) mechanism (OR = 6.56; 95% CI, 1.60-26.98); trauma resulting in fractures (OR = 3.03; 95% CI, 1.38-6.64); and private/commercial insurance (OR = 3.41; 95% CI, 1.10-10.55). CONCLUSION In this study population, a relatively high survival rate was noted (93.5%). Police transport of patients with blunt trauma was unexpectedly more common. Factors associated with survival to hospital discharge were identified. These factors can be used to implement more standardized and protocol-driven risk stratification tools of trauma patients on scene to improve police involvement in trauma patient transport.
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Nasser AAH, Khouli Y. The Impact of Prehospital Transport Mode on Mortality of Penetrating Trauma Patients. Air Med J 2020; 39:502-505. [PMID: 33228903 DOI: 10.1016/j.amj.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/10/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The optimal mode of transport of trauma patients from the scene to the hospital remains unknown. We aimed to study the impact of different prehospital modes of transport of penetrating trauma patients on hospital mortality. METHODS Using the Trauma Quality Improvement Program 2010 to 2016 database, we identified all adults with a penetrating injury. Univariate then multivariable logistic regression analyses were performed to study the correlation between the mode of transport and in-hospital mortality, adjusting for several covariates. RESULTS A total of 92,427 subjects were included. The overall mean transport time for patients transported by a ground ambulance, helicopter, fixed wing ambulance, and police/private vehicle were 32.2, 61.2, 68.9, and 28.2 minutes, respectively. Multivariable analyses revealed that compared with ground ambulance, helicopter transport was associated with a 34% decrease in the odds of mortality (odds ratio = 0.66, P < .0001), whereas police transport and private vehicle transport were associated with a 52% decrease in the odds of mortality (odds ratio = 0.48, P < .0001). CONCLUSION Helicopter, police, and private vehicle transports are associated with a decreased odds of mortality compared with ground ambulance. Further research should examine the variation in levels of care within different modes of prehospital transport.
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Affiliation(s)
- Ahmed A H Nasser
- Trauma and Orthopaedics Department, West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, Isleworth, United Kingdom.
| | - Yousef Khouli
- General Surgery Department, Broomfield Hospital, Mid Essex Hospitals NHS Trust, Broomfield, United Kingdom
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Koome G, Atela M, Thuita F, Egondi T. Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review. Trauma Surg Acute Care Open 2020; 5:e000530. [PMID: 33083557 PMCID: PMC7528423 DOI: 10.1136/tsaco-2020-000530] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/30/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa. METHODS A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate. RESULTS A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality. DISCUSSION Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, UK
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, Kenya
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Nasser AAH. Most of the Variation in Prehospital Scene Time Is Not Related to Patient Factors, Injury Characteristics, or Geography. Air Med J 2020; 39:374-379. [PMID: 33012475 DOI: 10.1016/j.amj.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The time spent on scene by emergency medical services remains highly variable. We sought to investigate how much of the prehospital scene time variation in penetrating trauma patients could be explained by prehospital factors. METHODS Using the 2010 to 2016 Trauma Quality and Improvement database, all adult penetrating trauma patients were included. The prehospital scene time was defined as the time from emergency medical service scene arrival to departure. Using all Trauma Quality and Improvement database variables including patient, injury (eg, Injury Severity Score), geography, and logistical (eg, transport mode) factors, multivariable linear regression models were created to predict the prehospital scene time. The prehospital scene time was treated as a continuous variable, and the degree to which the models could explain the variation in scene time was measured using the coefficient of determination (R). RESULTS A total of 45,560 patients were included. The median prehospital scene time was 6 minutes (interquartile range, 3-10 minutes). The R for factors in the multivariable regression model was 0.06, suggesting that 94% of the prehospital scene time variation cannot be explained by the wide range of prehospital factors. CONCLUSION Most of the variation in prehospital scene time cannot be explained by injury characteristics. The variation may be caused by logistical delays or system-related factors.
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Affiliation(s)
- Ahmed A H Nasser
- Trauma and Orthopaedics Department, West Middlesex University Hospital, Isleworth, UK.
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Bieler D, Paffrath T, Schmidt A, Völlmecke M, Lefering R, Kulla M, Kollig E, Franke A. Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®. Chin J Traumatol 2020; 23:224-232. [PMID: 32576425 PMCID: PMC7451614 DOI: 10.1016/j.cjtee.2020.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 01/02/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.
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Affiliation(s)
- Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, 40225, Germany,Corresponding author. Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany.
| | - Thomas Paffrath
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Faculty of Health – School of Medicine, Cologne, 51109, Germany
| | - Annelie Schmidt
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Maximilian Völlmecke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, 51109, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital Ulm, Ulm, 89081, Germany
| | - Erwin Kollig
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
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Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds. J Trauma Acute Care Surg 2020; 89:e16-e17. [DOI: 10.1097/ta.0000000000002725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nasser AAH, Nederpelt C, El Hechi M, Mendoza A, Saillant N, Fagenholz P, Velmahos G, Kaafarani HMA. Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients. Am J Surg 2020; 220:240-244. [PMID: 31761299 DOI: 10.1016/j.amjsurg.2019.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/02/2019] [Accepted: 11/11/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prompt surgical control of hemorrhage is crucial in penetrating trauma patients. We aimed to study the impact of prehospital response time (PreRespT) and scene time (SceneT) on hospital mortality. METHODS Using the Trauma Quality Improvement Program (TQIP) 2010-2016 database, we identified all adults with penetrating injury. We defined PreRespT as time from EMS dispatch to scene arrival, and SceneT as time spent on scene. Univariate then multivariable logistic regression analyses were performed to study the independent correlation between PreRespT and SceneT on hospital mortality, adjusting for several covariates. RESULTS Out of a total of 1,403,470 patients, 43,467 patients were included. Multivariable analyses suggested that: 1) every minute increase in PreRespT independently correlates with a 2% increase in mortality (OR 1.02, p < 0.0001), and 2) every minute increase in SceneT independently correlates with a 1% increase in mortality (OR 1.01, p = 0.001). CONCLUSION In the penetrating injury trauma patient, PreRespT and SceneT independently correlate with hospital mortality. This data suggests that a faster PreRespT and a "scoop and run" strategy may be more beneficial in this population.
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Affiliation(s)
- Ahmed A H Nasser
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlie Nederpelt
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds. J Trauma Acute Care Surg 2020; 87:1253-1259. [PMID: 31425474 DOI: 10.1097/ta.0000000000002483] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Shorter prehospital time in patients sustaining penetrating trauma has been shown to be associated with improved survival. Literature has also demonstrated that police transport (vs. Emergency Medical Services [EMS]) shortens transport times to a trauma center. The purpose of this study was to determine if ShotSpotter, which triangulates the location of gunshots and alerts police, expedited dispatch and transport of injured victims to the trauma center. METHODS All shootings which occurred in Camden, NJ, from 2010 to 2018 were reviewed. Demographic, geographic, response time, transport time, and field intervention data were collected from medical and police records. We compared shootings where the ShotSpotter was activated versus shootings where ShotSpotter was not activated. Incidents, which did not occur in Camden or where complete data were not available, were excluded as were patients not transported by police or EMS. RESULTS There were 627 shootings during the study period which met inclusion criteria with 190 (30%) activating the ShotSpotter system. Victims involved in shootings with ShotSpotter activation were more severely injured, more likely to be transported by police, less likely to undergo trauma bay resuscitative measures, and more likely to receive blood products. Mortality, when adjusted for distance, Trauma, and Injury Severity Score, Injury Severity Score, and shock index, was not significantly different between ShotSpotter and non-ShotSpotter incidents. ShotSpotter activation significantly reduced both the response time as well as transport time for both police and EMS (all p < 0.05). CONCLUSION The activation of the ShotSpotter technology increased the likelihood of police transport of gunshot victims. Furthermore, the use of this technology resulted in shorter response times as well as transport times for both police and EMS. This technology may be beneficial in enhancing the care of victims of penetrating trauma. LEVEL OF EVIDENCE Therapeutic/Care management, level III.
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Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg 2019; 153:107-113. [PMID: 28975247 DOI: 10.1001/jamasurg.2017.3601] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes. Objective To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems. Design, Setting, and Participants Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle. Main Outcome and Measure In-hospital mortality. Results Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups. Conclusions and Relevance Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.
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Affiliation(s)
- Michael W Wandling
- Division of Trauma and Critical Care, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Department of Surgery, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Avery B Nathens
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael B Shapiro
- Division of Trauma and Critical Care, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.,The Johns Hopkins University School of Public Health, Baltimore, Maryland
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Tatebe L, Speedy S, Kang D, Barnum T, Cosey-Gay F, Regan S, Stone L, Swaroop M. Empowering Bystanders to Intervene: Trauma Responders Unify to Empower (TRUE) Communities. J Surg Res 2019; 238:255-264. [PMID: 30954087 DOI: 10.1016/j.jss.2019.02.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/10/2019] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Timely and effective bystander first aid can improve outcomes for trauma victims. Bystanders are present at most traumas and are more likely to assist with prior training. MATERIALS AND METHODS An evidence-based course was created for the general public in high-risk Chicago neighborhoods focused on basic traumatic first aid, including scene management, hemorrhage control, and mitigating the psychological impact of trauma to overcome the bystander effect. Prospectively, participants completed knowledge-based and self-efficacy assessments precourse, postcourse, and 6 mo follow-up. The change in self-efficacy and knowledge scores was analyzed. RESULTS Over 32 courses, 503 participants were taught; 474 and 460 participants completed precourse and postcourse surveys, respectively, whereas 60 of 327 who consented for follow-up completed the 6-mo survey. Postcourse, participants were more likely to assist trauma victims and felt more confident in the quality of care they could provide; the effect remained significant at 6 mo (all P < 0.001). All seven self-efficacy empowerment-based questions individually demonstrated improvement from precourse to postcourse (P < 0.001), with an overall mean (SD) increase of 2.8 (2.1, P < 0.001); six maintained significance at follow-up with an overall mean increase of 2.8 (1.9, P < 0.001). Knowledge scores improved from 6.2 of 10 to 7.2 postcourse and 7.7 at follow-up (P < 0.001). Most improved were the ability to render first aid and apply tourniquets. CONCLUSIONS The TFRC increased self-efficacy, successfully teaching initial trauma care, particularly hemorrhage control and scene safety, suggesting that a grassroots approach to trauma care may improve outcomes in communities that experience high violence rates.
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Affiliation(s)
- Leah Tatebe
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Sedona Speedy
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Danby Kang
- Department of Surgery, Rush University, Chicago, Illinois
| | - Trevor Barnum
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Franklin Cosey-Gay
- Chicago Center for Youth Violence Prevention, University of Chicago, Chicago, Illinois
| | - Sheila Regan
- Cure Violence, University of Illinois, Chicago, Chicago, Illinois
| | - LeVon Stone
- Cure Violence, University of Illinois, Chicago, Chicago, Illinois
| | - Mamta Swaroop
- Department of Surgery, Northwestern University, Chicago, Illinois.
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Hirano Y, Abe T, Tanaka H. Efficacy of the presence of an emergency physician in prehospital major trauma care: A nationwide cohort study in Japan. Am J Emerg Med 2018; 37:1605-1610. [PMID: 30442432 DOI: 10.1016/j.ajem.2018.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The beneficial effect of the presence of an emergency physician in prehospital major trauma care is controversial. The aim in this study is to assess whether an emergency physician on scene can improve survival outcome of critical trauma patients. METHODS This retrospective cohort study was conducted by using nationwide trauma registry data between 2004 and 2013 in Japan. Severe trauma patients (injury severity score (ISS) ≥ 16) who were transported directly to the hospital from the injury site were included in our analysis. Patients who were predicted to be untreatable (abbreviated injury score (AIS) = 6 and/or cardiopulmonary arrest at least one time before hospital arrival) were excluded. Participants were divided into either a physician or paramedics group based on the prehospital practitioner. The primary outcome was survival rate at discharge. Multivariable logistic regression analysis was performed to compare the outcome with adjustment for age, gender, ISS, cause of injury, and pre-hospital vital signs. RESULTS A total of 30,283 patients were eligible for the selection criteria (physician: 1222, paramedics: 29,061). Overall, 172 patients (14.1%) died in the physician group compared to 3508 patients (12.1%) in the paramedics group. Patients in the physician group had higher ISSs than those in the paramedics group. In multivariable logistic regression, the physician group had an odds ratio (OR) of 1.16 (95% confidence interval (CI) = 0.97 to 1.40, p = 0.11) for in-hospital survival. CONCLUSIONS Our results failed to show a difference in survival at discharge between non-physician-staffed ambulances and physician-staffed ambulances.
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Affiliation(s)
- Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, Japan.
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, Japan; Department of Health Services Research, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, Japan.
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Möller A, Hunter L, Kurland L, Lahri S, van Hoving DJ. The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town. Afr J Emerg Med 2018; 8:89-94. [PMID: 30456155 PMCID: PMC6223589 DOI: 10.1016/j.afjem.2018.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/22/2017] [Accepted: 01/21/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa. METHODS The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant. RESULTS The majority of patients were 19-44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09). DISCUSSION Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.
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Affiliation(s)
- Anders Möller
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden
| | - Luke Hunter
- Khayelitsha Hospital, Private Bag X6, Khayelitsha, 7784 Cape Town, South Africa
| | - Lisa Kurland
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden
- Department of Medical Sciences, Örebro University, School of Medical Sciences, Campus USÖ, S-701 82 Örebro, Sweden
- Department of Emergency Medicine, Örebro University Hospital, School of Medical Sciences, Campus USÖ, S-701 82 Örebro, Sweden
| | - Sa'ad Lahri
- Khayelitsha Hospital, Private Bag X6, Khayelitsha, 7784 Cape Town, South Africa
| | - Daniël J. van Hoving
- Division of Emergency Medicine, Stellenbosch University, Private Bag X1, Matieland, 7602 Stellenbosch, Cape Town, South Africa
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Klassen AB, Marshall M, Dai M, Mann NC, Sztajnkrycer MD. Emergency Medical Services Response to Mass Shooting and Active Shooter Incidents, United States, 2014-2015. PREHOSP EMERG CARE 2018; 23:159-166. [PMID: 30118358 DOI: 10.1080/10903127.2018.1484970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The purpose of the current study was to describe the injury patterns, EMS response and interventions to mass shooting (MS) and active shooter (AS) incidents. METHODS Retrospective analysis of 2014-2015 National Emergency Medical Services Information System (NEMSIS) data sets. Date, time, and location for MS incidents were obtained from the Gun Violence Archive and then correlated with NEMSIS data set records. AS incidents were identified through Federal Bureau of Investigation (FBI) data. A de-identified database was generated for final analysis. RESULTS A total of 608 MS incidents were identified, of which 19 were also classified as AS incidents. NEMSIS patient care data was available for 652 EMS activations representing 226 unique MS incidents. Thirty-four EMS responses to 5 unique AS incidents were similarly identified: 76% of victims were male and 80% of victims were African American. Dispatch complaint did not suggest shooting (potentially dangerous scene environment) in 15.9% of records. The most commonly reported incident locations for MS were Street/Highway (38.2%) and Home/Residence (32.4%). Location of wounds included extremities (49%), chest (12%), and head/neck (13%). Tourniquet use was documented in 6 victims. 35.9% of victims were transported to the closest facility. CONCLUSIONS MS and AS incidents are prevalent in the United States. Despite the fact that extremity wounds were common, documented EMS tourniquet use was uncommon. While MS events are high risk for responders, dispatch information was lacking in almost 15% of records. Responding EMS agencies were diverse, emphasizing the need to ensure all EMS providers are prepared to respond to MS incidents.
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Anderson JE, Galante JM, Salcedo ES. Questioning the Benefits of Private Vehicle Transportation vs Emergency Medical Services Transportation. JAMA Surg 2018. [PMID: 29541775 DOI: 10.1001/jamasurg.2018.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jamie E Anderson
- Division of Trauma and Acute Care Surgery, University of California Davis Medical Center, Sacramento
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, University of California Davis Medical Center, Sacramento
| | - Edgardo S Salcedo
- Division of Trauma and Acute Care Surgery, University of California Davis Medical Center, Sacramento
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Smith RF. Questioning the Benefits of Private Vehicle Transportation vs Emergency Medical Services Transportation. JAMA Surg 2018. [DOI: 10.1001/jamasurg.2018.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Robert F. Smith
- Former Division of Prehospital Care and Prevention, Department of Trauma, John H. Stroger Jr Hospital of Cook County, Chicago, Illinois
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Smith ER, Shapiro G, Sarani B. Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event. PREHOSP EMERG CARE 2018; 22:662-668. [PMID: 29693490 DOI: 10.1080/10903127.2018.1459980] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma. METHODS A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury. RESULTS There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head. CONCLUSIONS A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.
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Ruelas OS, Tschautscher CF, Lohse CM, Sztajnkrycer MD. Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients. PREHOSP EMERG CARE 2018; 22:691-697. [PMID: 29617208 DOI: 10.1080/10903127.2018.1448494] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries. METHODS We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury. RESULTS A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively. CONCLUSIONS Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.
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Aljerian N, Alhaidar S, Alothman A, AlJohi W, Albaqami FA, Alghnam SA. Association between the mode of transport and in-hospital medical complications in trauma patients: findings from a level-I trauma center in Saudi Arabia. Ann Saudi Med 2018; 38:8-14. [PMID: 29419523 PMCID: PMC6074188 DOI: 10.5144/0256-4947.2018.8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Saudi Arabia, injury is the leading cause of death. Even if nonfatal, the impact of injuries on population health is enormous, as thousands of young patients suffer permanent disabilities every year. Unlike in developed countries, private transportation (PT) is a common means to transport trauma patients. Outcome differences between patients transported via PT relative to emergency medical services (EMS) has not been previously explored. OBJECTIVES To evaluate the association between transportation mode and in-hospital complications among trauma patients. DESIGN Retrospective. SETTING Tertiary care center. PATIENTS AND METHODS The study included all patients (>=16 years), who were admitted following trauma. MAIN OUTCOME MEASURES The main outcome in the study was the occurrence of any medical complications including stroke, sepsis, myocardial infarction, pulmonary embolism, pneumonia, renal failure, acute respiratory distress syndrome, and cardiac arrest. RESULTS The 493 patients were relatively young (over two-thirds of the sample were 45 years old or younger) and over half the population sustained injuries due traffic crashes. More than half (58%) of patients arrived via private transportation. Regression analyses revealed that in-hospital complications following injuries were significantly lower among those who arrived via PT. However, after incorporating propensity score matching, we found no difference in hospital complications (OR=0.55, 95% CI 0.25-1.17). CONCLUSION Multiple factors may influence this unexpected finding, such as distance to health care set.tings, the belief that PT is faster or lack of knowledge of the EMS contact number. Further efforts are needed to raise awareness of the importance of using EMS to transport trauma patients to hospitals. Prevention programs to reduce traffic crashes may facilitate reduction in traumatic injuries and associated complications. LIMITATIONS Retrospective and conducted in one center only.
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Affiliation(s)
| | | | | | | | | | - Suliman Abdullah Alghnam
- Dr. Suliman Abdulah Alghnam Population Health, King Abdullah International Research Center, PO Box 22490, Riyadh 11426, Saudi Arabia T: +966-539468887, , ORCID: http://orcid.org/0000-0001-5817-0481
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Celik S, Dursun R, Aycan A, Gönüllü H, Adanaş C, Eryılmaz M, Gönüllü E, Akyol ME, Keskin S, Güloğlu C. The dynamics of prehospital/hospital care and modes of transport during civil conflict and terrorist incidents. Public Health 2017; 152:108-116. [PMID: 28886492 DOI: 10.1016/j.puhe.2017.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/17/2017] [Accepted: 07/27/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Prehospital and hospital care during incidents of mass violence and civil conflict involve a number of aspects that distinguish it from care during times of peace. We aimed to analyze the dynamics and outcomes of prehospital and hospital care during ongoing conflicts. STUDY DESIGN Multicentric prospective observational study. METHOD Patients enrolled in the study, which was conducted in Turkey, were all injured in armed conflict and taken to level 1 trauma centers. On admittance, patients were requested to complete a semistructured questionnaire containing questions on patient demographics, transport type, weapons used, injury severity score (ISS), and other incident-related factors. We analyzed patient outcomes (mortality, morbidity, complications, and length of hospital stay) and transfers of patients between hospitals. The present study evaluated the cases of 390 victims enrolled over a 9-month period and followed up for 6 months. RESULTS The majority of patients were transported by ambulances (n = 334, 85.6%); other transport modes were helicopters (n = 32, 8.2%) and private vehicles (n = 24, 6.2%). Nearly half of patients (48.7%) did not benefit by changing hospitals. During transport to hospitals, 4.1% of the vehicles in the study were involved in accidents. Using multiple regression analysis, only ISS (odds ratio [OR]: 1.098, 95% confidence interval [CI]: 1.044-1.156) and the Glasgow Coma Scale (OR: 0.744, 95% CI: 0.639-0.866) were found to affect mortality. In Receiver-operator characteristic analysis, a cutoff value of 22.5 for ISS had a sensitivity of 100% and a specificity of 89.6% for mortality. CONCLUSIONS Despite lower ISS values, patient outcomes were worse in terror incidents/civil conflicts. Transport modes did not significantly affect outcomes, whereas hospital transport was found to be inefficiently used.
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Affiliation(s)
- S Celik
- Department of General Surgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey.
| | - R Dursun
- Department of Emergency Medicine, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - A Aycan
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - H Gönüllü
- Department of Emergency Medicine, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - C Adanaş
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - M Eryılmaz
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - E Gönüllü
- Anesthesiology and Reanimation Clinic, Van Research and Training Hospital, Van, Turkey
| | - M E Akyol
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - S Keskin
- Department of Biostatistics, Faculty of Medicine, Yuzuncu Yıl University, Van, Turkey
| | - C Güloğlu
- Department of Emergency Medicine, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
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Lale A, Krajewski A, Friedman LS. Undertriage of Firearm-Related Injuries in a Major Metropolitan Area. JAMA Surg 2017; 152:467-474. [PMID: 28114435 DOI: 10.1001/jamasurg.2016.5049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance National anatomic triage criteria prescribe specific transport rules for injured patients. However, there is limited information about patients with firearm-related injuries undertriaged to nondesignated facilities (ie, hospitals without specialized trauma teams or units), including what clinical outcomes are achieved and how many are transferred to a higher level of care. Without these data, it is difficult to make informed regional or national policy decisions about triage practices. Undertriage of firearm-related injuries is a good model for evaluating the undertriage of patients with trauma because the anatomic triage criteria for patients with firearm-related injuries are simple. Objective To evaluate the prevalence, spatial distribution, and clinical outcomes of undertriage of firearm-related injuries. Design, Setting, and Participants This study is a retrospective analysis of firearm-related injuries in residents of Cook County, Illinois, from January 1, 2009, to December 31, 2013. Outpatient and inpatient hospital databases were used. Participants included patients with International Classification of Diseases, Ninth Revision, Clinical Modification firearm-related cause-of-injury codes. Data were collected all at once in August 2014. Data analysis took place from March 12, 2015, to February 1, 2016. Main Outcomes and Measures Undertriaged cases were defined as patients who met the national anatomic triage criteria for transfer to higher-level trauma center care. Spatial distribution, injury severity, and clinical outcomes, including death, were analyzed. Results Of the 9886 patients included in this analysis, 8955 (90.6%) were male, 7474 (75.6%) were African American, and 5376 (54.4%) were aged 15 to 24 years.In Cook County, Illinois, where there are 19 trauma centers, 2842 of 9886 (28.7%) firearm-related injuries were initially treated in nondesignated facilities. Among the 4934 cases with firearm-related injury who met the anatomic triage criteria, 884 (17.9%) received initial treatment at a nondesignated facility and only 92 (10.4%) were transferred to a designated trauma center. Significant spatial clustering was identified on the west side of Chicago and in the southern parts of Chicago and Cook County. In the multivariable models, patients treated in nondesignated facilities were less likely to die than were patients treated in designated trauma centers. Conclusions and Relevance Undertriage of firearm-related injuries was much more prevalent than expected. Although the likelihood of dying during hospitalization was greater among patients treated in designated trauma centers, these patients were substantially in worse condition across all measures of injury severity. A smaller proportion of patients treated in designated trauma centers died during the first 24 hours of hospitalization. This study highlights the need for better regional coordination, especially with interhospital transfers, as well as the importance of assessing the distribution of emergency medical services resources to make the trauma care system more effective and equitable.
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Affiliation(s)
- Allison Lale
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago
| | - Allison Krajewski
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago
| | - Lee S Friedman
- Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago
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Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes. J Trauma Acute Care Surg 2017; 81:931-935. [PMID: 27537514 DOI: 10.1097/ta.0000000000001228] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport. METHODS Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived. RESULTS Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50). CONCLUSIONS Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Bieler D, Franke A, Lefering R, Hentsch S, Willms A, Kulla M, Kollig E. Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU ®). Injury 2017; 48:32-40. [PMID: 27586065 DOI: 10.1016/j.injury.2016.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/11/2016] [Accepted: 08/26/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome. MATERIAL AND METHODS In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock. RESULTS Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation. CONCLUSION This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.
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Affiliation(s)
- Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany.
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Sebastian Hentsch
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Erwin Kollig
- Department of Trauma Surgery and Orthopaedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072 Koblenz, Germany
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- Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany
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Rossignol M. Trauma and pregnancy: What anesthesiologist should know. Anaesth Crit Care Pain Med 2016; 35 Suppl 1:S27-S34. [PMID: 27386762 DOI: 10.1016/j.accpm.2016.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mathias Rossignol
- Department of anesthesiology, critical care and pre-hospital intensive care unit, hôpital Lariboisière, Assistance publique-Hopitaux de Paris, Paris, France.
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Holst JA, Perman SM, Capp R, Haukoos JS, Ginde AA. Undertriage of Trauma-Related Deaths in U.S. Emergency Departments. West J Emerg Med 2016; 17:315-23. [PMID: 27330664 PMCID: PMC4899063 DOI: 10.5811/westjem.2016.2.29327] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 02/03/2023] Open
Abstract
Introduction Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers. Methods This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression. Results We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]). Conclusion We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.
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Affiliation(s)
- Jenelle A Holst
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Sarah M Perman
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Roberta Capp
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Jason S Haukoos
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Adit A Ginde
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Huber S, Crönlein M, von Matthey F, Hanschen M, Seidl F, Kirchhoff C, Biberthaler P, Lefering R, Huber-Wagner S. Effect of private versus emergency medical systems transportation in trauma patients in a mostly physician based system- a retrospective multicenter study based on the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med 2016; 24:60. [PMID: 27121607 PMCID: PMC4849091 DOI: 10.1186/s13049-016-0252-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 04/20/2016] [Indexed: 11/10/2022] Open
Abstract
Background The effects of private transportation (PT) to definitive trauma care in comparison to transportation using Emergency Medical Services (EMS) have so far been addressed by a few studies, with some of them finding a beneficial effect on survival. The aim of the current study was to investigate epidemiology, pre- and in-hospital times as well as outcomes in patients after PT as compared to EMS recorded in the TraumaRegister DGU®. Methods All patients in the database of the TraumaRegister DGU® (TR-DGU) from participating European trauma centers treated in 2009 to 2013 with available data on the mode of transportation, ISS ≥ 4 and ICU treatment were included in the study. Epidemiological data, pre- and in-hospital times were analysed. Outcomes were analysed after adjustment for RISC-II scores. Results 76,512 patients were included in the study, of which 1,085 (1.4 %) were private transports. Distribution of ages and trauma mechanisms showed a markedly different pattern following PT, with more children < 15 years treated following PT (3.3 % EMS vs. 9.6 for PT) and more elderly patients of 65 years or older (26.6 vs 32.4 %). Private transportation to trauma care was by far more frequent in Level 2 and 3 hospitals (41.2 % in EMS group vs 73.7 %). Median pre-hospital times were also reduced following PT (59 min for EMS vs. 46 for PT). In-hospital time in the trauma room (66 for EMS vs. 103 min for PT) and time to diagnostics were prolonged following PT. Outcome analysis after adjustment for RISC-II scores showed a survival benefit of PT over EMS transport (SMR for EMS 1.07 95 % CI 1.05–1.09; for PT 0.85 95 % CI 0.62–1.08). Discussion The current study shows a distinct pattern concerning epidemiology and mechanism of injury following PT. PT accelerates the median pre-hospital times, but prolongs time to diagnostic measures and time in the trauma room. Conclusions In this distinct collective, PT seemed to lead to a small benefit in terms of mortality, which may reflect pre-hospital times, pre-hospital interventions or other confounders.
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Affiliation(s)
- Stephan Huber
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany.
| | - Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Francesca von Matthey
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Marc Hanschen
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Fritz Seidl
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, University Witten/Herdecke, Faculty of Health, Ostmerheimer Str. 200, D-51109, Cologne, Germany
| | - Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich - TUM, Ismaninger Str. 22, D-81675, Munich, Germany
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