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Bulger EM, Bixby PJ, Price MA, Villarreal CL, Moreno AN, Herrera-Escobar JP, Bailey JA, Brasel KJ, Cooper ZR, Costantini TW, Gibran NS, Groner JI, Joseph BA, Newgard CD, Stein DM. An Executive Summary of the National Trauma Research Action Plan (NTRAP). J Trauma Acute Care Surg 2024:01586154-990000000-00669. [PMID: 38523118 DOI: 10.1097/ta.0000000000004279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.
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Price MA, Villarreal CL, Moreno AN, Flayter R, Herrera-Escobar JP, Sims CA, Bulger EM. Developing a National Trauma Research Action Plan (NTRAP): Results from the Regulatory Challenges Delphi Survey. J Trauma Acute Care Surg 2023:01586154-990000000-00578. [PMID: 38031274 DOI: 10.1097/ta.0000000000004185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND In 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM) issued a report calling for a National Trauma Research Action Plan requiring a resourced, coordinated, joint approach to trauma care research. The NASEM report recommended the identification of regulatory barriers to trauma research. The NTRAP Regulatory Challenges Panel of trauma researchers and regulatory professionals was convened to identify the most challenging aspects of regulatory processes involved in conducting research. METHODS Trauma researchers and regulatory experts were recruited to identify and rate challenging regulatory issues in 2021-2022. Challenge statements were developed from a comprehensive scoping review. Panelists rated the challenge level for each statement on a 9-point Likert scale. The Delphi survey was conducted over 3 online rounds. Consensus was defined a priori as ≥60% agreement. Results of the Delphi survey were presented to the panel during a webinar. Panel participants then participated in breakout sessions to strategize solutions, share lessons learned and identify where more regulatory guidance is needed. RESULTS Thirty-eight subject matter experts rated 175 regulatory challenges, of which 141 reached the consensus threshold (81%). Of the consensus-reaching challenge statements, 42 had a challenge rating of 6 or higher. Among the highest-rated challenges were issues pertaining to conducting pre-hospital research, Exception From Informed Consent, mistrust of research among various racial and ethnic groups, and issues specific to conducting pediatric trauma research. CONCLUSIONS This Delphi survey rated challenges culled from a regulatory literature scoping review. The panel identified the most challenging aspects of human subjects protection while conducting trauma research and recommended strategies and best practices to address them. The findings from this study were used to develop the NTRAP Investigator Toolkit which is available on the internet as a resource for trauma researchers. LEVEL OF EVIDENCE Expert consensus. TYPE OF STUDY Original research/Expert consensus.
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Medrano NW, Villarreal CL, Price MA, Bixby PJ, Bulger EM, Eastridge BJ. Access to trauma center care: A statewide system-based approach. J Trauma Acute Care Surg 2023; 95:242-248. [PMID: 37158782 DOI: 10.1097/ta.0000000000004002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care. METHODS Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access. RESULTS The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%). CONCLUSION This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Nicolas W Medrano
- From the Coalition for National Trauma Research (N.W.M., C.L.V., M.A.P., P.J.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; and Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas
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Medrano NW, Villarreal CL, Mann NC, Price MA, Nolte KB, MacKenzie EJ, Bixby P, Eastridge BJ. Activation and On-Scene Intervals for Severe Trauma EMS Interventions: An Analysis of the NEMSIS Database. PREHOSP EMERG CARE 2023; 27:46-53. [PMID: 35363117 DOI: 10.1080/10903127.2022.2053615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.
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Affiliation(s)
| | | | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Kurt B Nolte
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Ellen J MacKenzie
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Pam Bixby
- Coalition for National Trauma Research, San Antonio, Texas
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Villarreal CL, Price MA, Moreno AN, Zenteno A, Saenz C, Toppo A, Herrera-Escobar JP, Sims CA, Bulger EM. Regulatory challenges in conducting human subjects research in emergency settings: the National Trauma Research Action Plan (NTRAP) scoping review. Trauma Surg Acute Care Open 2023; 8:e001044. [PMID: 36895783 PMCID: PMC9990621 DOI: 10.1136/tsaco-2022-001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/08/2023] [Indexed: 03/11/2023] Open
Abstract
The complexity of the care environment, the emergent nature, and the severity of patient injury make conducting clinical trauma research challenging. These challenges hamper the ability to investigate potentially life-saving research that aims to deliver pharmacotherapeutics, test medical devices, and develop technologies that may improve patient survival and recovery. Regulations intended to protect research subjects impede scientific advancements needed to treat the critically ill and injured and balancing these regulatory priorities is challenging in the acute setting. This scoping review attempted to systematically identify what regulations are challenging in conducting trauma and emergency research. A systematic search of PubMed was performed to identify studies published between 2007 and 2020, from which 289 articles that address regulatory challenges in conducting research in emergency settings were included. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Most articles identified were editorial/commentary (31%) and published in the USA (49%). Regulatory factors addressed in the papers were categorized under 15 regulatory challenge areas: informed consent (78%), research ethics (65%), institutional review board (55%), human subjects protection (54%), enrollment (53%), exception from informed consent (51%), legally authorized representative (50%), patient safety (41%), community consultation (40%), waiver of informed consent (40%), recruitment challenges (39%), patient perception (30%), liability (15%), participant incentives (13%), and common rule (11%). We identified several regulatory barriers to conducting trauma and emergency research. This summary will support the development of best practices for investigators and funding agencies.
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Affiliation(s)
| | | | - Ashley N Moreno
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | - Alfonso Zenteno
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | - Christine Saenz
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | - Alexander Toppo
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | | | - Carrie A Sims
- Division of Trauma, Critical Care, and Burn, The Ohio State University, Columbus, Ohio, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
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Medrano NW, Villarreal CL, Price MA, MacKenzie E, Nolte KB, Phillips MJ, Stewart RM, Eastridge BJ. Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment (MIMIC): a methodology for reliably measuring prehospital time and distance to definitive care. Trauma Surg Acute Care Open 2019; 4:e000309. [PMID: 31058244 PMCID: PMC6461208 DOI: 10.1136/tsaco-2019-000309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/25/2019] [Indexed: 11/04/2022] Open
Abstract
The detailed study of prehospital injury death is critical to advancing trauma and emergency care, as circumstance and causality have significant implications for the development of mitigation strategies. Though there is no true 'Golden Hour,' the time from injury to care is a critical element in the analysis matrix, particularly in patients with severe injury. Currently, there is no standard method for the assessment of time to definitive care after injury among prehospital deaths. This article describes a methodology to estimate total prehospital time and distance for trauma patients transported via ground emergency medical services and helicopter emergency medical services using a geographic information system. Data generated using this method, along with medical examiner and field investigation reports, will be used to estimate the potential survivability of prehospital trauma deaths occurring in five US states and the District of Columbia as part of the Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment study. One goal of this work is to develop standard metrics for the assessment of total prehospital time and distance, which can be used in the future for more complex spatial analyses to gain a deeper understanding of trauma center access. Results will be used to identify high priority areas for research and development in injury prevention, trauma system performance improvement, and public health.
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Affiliation(s)
| | | | | | - Ellen MacKenzie
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kurt B Nolte
- Office of the Medical Investigator, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Ronald M Stewart
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA
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Villarreal CL. Control and eradication strategies of avian influenza in Mexico. Dev Biol (Basel) 2006; 124:125-6. [PMID: 16450453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
In December 1994, a highly pathogenic (HP) avian influenza (AI) outbreak occurred in Mexico, caused by the subtype H5N2, affecting two main regions of egg and poultry-meat production. At that time, governmental actions included immediate stamping out of the affected flocks, disinfection of affected premises, quarantine measures in the region, strict movement controls on poultry and their products and vaccination. With these policies, the disease was eradicated in a relatively short time. The last case of HPAI was detected in June 1995 and the country was declared as free of HPAI virus in January 1996 to the World Animal Health Organisation (OIE). Since then, Mexico has maintained a control programme against low pathogenic (LP) AI virus that is based on a zoning classification, movement controls and other strategies.
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Affiliation(s)
- C L Villarreal
- Mexico-United States Commission for the Prevention of Foot and Mouth Disease and other Exotic Animal Diseases, Animal Health General Directorate, Senasica, Sagarpa, Mexico.
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