The Challenges and Strategies of Affordable Care Act Navigators and In-Person Assisters with Enrolling Uninsured, Violently Injured Young Black Men into Healthcare Insurance Coverage.

Low-income young Black men experience a disproportionate burden of violent injury in the United States. These men face significant disparities in healthcare insurance coverage and access to care. The Affordable Care Act (ACA) created a new healthcare workforce, Navigators and In-Person Assisters (IPAs), to support low-income minority populations with insurance enrollment. Using a longitudinal qualitative case study approach with Navigators and IPAs at the two busiest urban trauma centers in Maryland, this study identifies the culturally and structurally responsive enrollment strategies used by three Navigators/IPAs as they enrolled violently injured young Black men in healthcare insurance coverage. These approaches included gaining their trust and building rapport and engaging female caregivers during enrollment. Navigators and IPAs faced significant barriers, including identity verification, health literacy, privacy and confidentiality, and technological issues. These findings offer novel insight into the vital work performed by Navigators and IPAs, as they attempt to decrease health disparities for young Black male survivors of violence. Despite high rates of victimization due to violent firearm injury, little is known about how this population gains access to healthcare insurance. Although the generalizability of this research may be limited due to the small sample size of participants, the qualitative case study approach offers critical exploratory data suggesting the importance of trauma-informed care in insurance enrollment by Navigators and IPAs. They also emphasize the need to further address structural issues, which affect insurance enrollment and thus undermine the well-being of young Black men who have survived violent injury.

Prevention Professional for Violence Intervention: A Newly Recognized Health Care Provider for Population Health Programs.

The National Uniform Claim Committee recognized a new type of health care provider for violence intervention: prevention professional. This creates a pathway for population health interventions to obtain reimbursement through traditional medical financing systems. In addition to violence, prevention professionals may specialize in other conditions of public health importance.

Methodological Considerations for Research With Black Male Victims of Violent Injury in an Urban Trauma Unit.

There is a body of research over the last three decades that has focused on the etiology of violence among victims of violent injury. This body of literature indicates that Black men are disproportionately represented among victims of violent injury seen in emergency departments and trauma centers across the country. Despite the disproportionate number of low-income young Black men treated for violent injury in urban trauma units and the growing body of literature accompanying it, little is known about the unique methodological challenges violent injury researchers face when conducting research on this vulnerable population in a clinical setting. This article describes the unique and often nuanced methodological difficulties a research team encountered while conducting a longitudinal qualitative study on risk factors for repeat violent injury among low-income young Black male victims of violent injury treated at a Level II trauma center in the Eastern United States. Four methodological challenges are identified: (a) the identification and screening of participants, (b) recruitment and interviewing, (c) understanding hospital culture, policies, and procedures, and (d) retention and attrition of sample. Recommendations to overcome these challenges are offered.

Risk factors for recurrent violent injury among black men.

BACKGROUND: Black men are disproportionately overrepresented among victims of repeat violent injury. However, little is known about the risk factors that influence violent trauma recidivism among black men. We hypothesize that the following risk factors would be significant among black male victims of repeat violent injury: disrespect; being under the influence; being in a fight and using a weapon in the past year; and previous incarceration when comparing trauma recidivists versus nonrecidivists. METHODS: Using secondary data analysis, we identified a sample of 191 (n = 191) urban low-income black men treated by a level I trauma unit in Baltimore for violent injury (e.g., gunshot wound, stabbing, or assault) who participated in a hospital-based violence intervention program from 1998 to 2011. Participants in the program completed a risk factor for violent injury questionnaire to assess: exposure to chronic violence, criminal justice involvement, substance abuse, and disrespect (code of the street). RESULTS: We found that 58% of the sample is characterized as trauma recidivists (defined as hospitalization two or more times for violent injury). Black male patients of violent injury who engage in the following: substance abuse; had previously been in a fight or used a weapon in the past year; perceived disrespect as a precursor to violence; and experienced a previous incarceration were more likely to have multiple hospitalizations for violent injury. CONCLUSIONS: Trauma recidivism among urban black male victims of violent injury is a major public health issue. Hospital-based violence intervention programs should be engaged in reducing trauma recidivism among this population.

Who Shot Ya? How Emergency Departments Can Collect Reliable Police Shooting Data.

This paper examines an alternative solution for collecting reliable police shooting data. One alternative is the collection of police shooting data from hospital trauma units, specifically hospital-based violence intervention programs. These programs are situated in Level I trauma units in many major cities in USA. While the intent of these programs is to reduce the risk factors associated with trauma recidivism among victims of violent injury, they also collect reliable data on the number of individuals treated for gunshot wounds. While most trauma units do a great job collecting data on mode of injury, many do not collect data on the circumstances surrounding the injury, particularly police-involved shootings. Research protocol on firearm-related injury conducted in emergency departments typically does not allow researchers to interview victims of violent injury who are under arrest. Most victims of nonfatal police-involved shootings are under arrest at the time they are treated by the ED for their injury. Research protocol on victims of violent injury often excludes individuals under arrest; they fall under the exclusion criteria when recruiting potential participants for research on violence. Researchers working in hospital emergency departments are prohibited from recruited individuals under arrests. The trauma staff, particularly ED physicians and nurses, are in a strategic position to collect this kind of data. Thus, this paper examines how trauma units can serve as an alternative in the reliable collection of police shooting data.

S-100ß does not predict outcome after mild traumatic brain injury.

OBJECTIVE: To determine the usefulness of S-100ß, a marker for central nervous system damage, in the prediction of long-term outcomes after mild traumatic brain injury (MTBI) Hypothesis: Mid- and long-term outcomes of MTBI (i.e. 3, 6 and 12 months post-injury and return-to-work or school (RTWS)) may be predicted based on pre-injury and injury factors as well as S-100ß. METHODS: MTBI subjects without abnormal brain computed tomography requiring intervention, focal neurological deficits, seizures, amnesia > 24 hours and severe or multiple injuries were recruited at a level I trauma centre. Admission S-100ß measurements and baseline Concussion Symptom Checklist were obtained. Symptoms and RTWS were re-assessed at follow-up visits (3-10 days and 3, 6 and 12 months). Outcomes included number of symptoms and RTWS at follow-up. Chi-square tests, linear and logistic regression models were used and p < 0.05 was considered statistically significant. RESULTS: One hundred and fifty of 180 study subjects had S-100ß results. Eleven per cent were unable to RTWS at 12 months. S-100ß levels were not associated with post-concussive symptomatology at follow-up. In addition, no association was found between S-100ß levels and RTWS. CONCLUSION: Amongst MTBI patients, S-100ß levels are not associated with prolonged post-concussive syndrome or the inability to RTWS.

Predictors of outcome in civilian gunshot wounds to the head.

OBJECT: Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period. METHODS: The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data. RESULTS: Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome. CONCLUSIONS: Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Does helicopter transport improve outcomes independently of emergency medical system time?

BACKGROUND: Helicopter emergency medical systems (HEMS) have been reported to improve trauma survival. This study seeks to determine HEMS effect on survival across different subpopulations in relation to injury severity, degree of physiologic derangement, and transportation time (TT). METHODS: The 2007 National Trauma Data Bank adult patients transported directly to hospitals by ground ambulance or HEMS were compared in relation to their survival with discharge and other possible confounders. Multivariate models were constructed to determine the adjusted odds ratios (OR) of survival for the entire cohort and across subpopulations stratified by different Injury Severity Score (ISS), hospital Revised Trauma Score (RTS), and TT. RESULTS: A total of 192,422 patients with complete data were analyzed. HEMS patients (15.3%) experienced lower survival rates than those transported by ground (93.8% vs. 96.1%, p < 0.001). Multivariate analysis revealed a survival advantage for HEMS in the entire cohort (OR, 1.78 [1.65-1.92]). Adding TT to the model did not affect HEMS effect on survival. HEMS effect was present across all ISS levels but was limited to those with RTS of less than 6 (n = 15,427; OR, 2.28 [2.10-2.49]). In contrast, those with RTS of 6 or greater experienced lower adjusted survival when transported by HEMS (n = 176,995; OR, 0.83 [0.74-0.94]). Stratification by RTS and ISS did not affect the results. Substratification by TT revealed no effect of HEMS on survival among patients with RTS of less than 6, ISS of less than 16, and TT of 60 minutes or greater. Remaining associations were not affected by TT substratification. CONCLUSION: HEMS beneficial effect on survival seems to be limited to patients with physiologic instability. Physiologically stable patients seem to have a worse outcome when transported by air. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Delayed trauma team activation: patient characteristics and outcomes.

BACKGROUND: The study aimed to characterize factors linked to delayed trauma team activation (DTTA) and to establish whether these delays are linked to worse outcomes. METHODS: Registry data were analyzed in regard to DTTA for years 2008 to 2010 at a Level II trauma center. DTTA was defined as cases when a trauma team activation or trauma consult occurred more than 30 minutes after arrival at the emergency department in the presence of triaging criteria or clinical evidence of traumatic injury. Characteristics and outcomes were studied in relation to DTTA using contingency tables (χ test), Student's t tests, Wilcoxon statistics, and multivariate methods. RESULTS: DTTA occurred in 1.5% of the 9,525 patients and was significantly linked to age of 55 years or older, nonwhite ethnicity, blunt assault (i.e., struck with blunt object), Injury Severity Score of 16 or higher, Glasgow Coma Scale (GCS) score of 15, and head injury with maximum Abbreviated Injury Scale score of 3 or higher (MAIS3+). Firearm and motor vehicular injuries were significantly less common among those with DTTA. No link was found for sex, falls, stabbings, or blood alcohol concentration (BAC) of 80 mg/dL or more. Although mortality did not differ, hospital stay was longer, and discharge to rehabilitation was more common among those with DTTA. Multivariate models predicting DTTA revealed significant associations with age of more than 55 years (odds ratio [OR], 3.77 [2.54-5.53]), white ethnicity (OR, 0.47 [0.27-0.76]), blunt assault (OR, 3.42 [2.20-5.19]), and GCS score of 15 (OR, 4.48 [2.02-12.71]). Multivariate analyses did not reveal any association of DTTA with length of stay and mortality. CONCLUSION: DTTA occurs infrequently and is linked to older age, nonwhite ethnicity, blunt assaults, and normal GCS score. The higher rates of MAIS3+ head injuries with a maximum Abbreviated Injury Scale score of more than 3 among those with DTTA should encourage better recognition of those with these injuries. LEVEL OF EVIDENCE: Prognostic study, level III.

Race/ethnicity and acute respiratory distress syndrome: a National Trauma Data Bank study.

BACKGROUND: A study in the general population has shown a higher acute respiratory distress syndrome (ARDS) mortality among blacks. We studied whether black blunt-trauma patients experience different ARDS incidence, ARDS-associated mortality, or ARDS case fatality rates. METHODS: National Trauma Data Bank (NTDB) extracts of blunt-trauma patients with Injury Severity Score (ISS) greater than 16 and length of stay greater than 3 days were used for this study. ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were calculated for Caucasians, blacks, and Hispanics, and compared using chi2. In order to adjust for confounders (age, gender, comorbidities, hypotension, and injury severity) multiple logistic regression models were built for the 3 outcomes. Odd ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p < .05 was used for all statistics. RESULTS: Among the 96350 patients studied, ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were 0.92%, 0.18%, and 19.1%, respectively. Differences among racial/ethnic groups were found between blacks and Caucasians for ARDS incidence (0.70% vs. 0.93%) and between Hispanic and Caucasians for ARDS-associated mortality (0.27% vs. 0.17%). Multiple logistic regression models adjusting for confounders, using Caucasian race/ethnicity as a reference, revealed a protective effect of black race/ethnicity for ARDS incidence (OR, 0.73; 95% CI, 0.58-0.91). Hispanics, but not blacks, experienced higher odds of adjusted ARDS-associated mortality (OR, 1.76; 95% CI, 1.15-2.62) and ARDS case fatality (OR, 1.92; 95% CI, 1.17-3.09). CONCLUSIONS: Black race/ethnicity is not associated with ARDS mortality among blunt-trauma patients. Black race/ethnicity seems to have a protective effect in relation to ARDS incidence. Hispanic ethnicity was associated with a higher mortality and case fatality rates for ARDS.

Suicides, homicides, and unintentional injury deaths after trauma center discharge: cocaine use as a risk factor.

BACKGROUND: : To study whether trauma center patients with positive toxicology findings for cocaine-positive (COC+) are at a higher risk for suicide, homicide, and unintentional injury death after discharge than cocaine-negative (COC+) trauma patients. METHODS: : Patients admitted between July 1983 and June 1995 and discharged alive from a level I trauma center were prospectively followed up for 1.5 years to 14.5 years. The occurrence of suicide, homicide, and unintentional injury death was explored in relation to COC+ status at admission using Cox proportional hazards methodology. Models included possible confounders. Interactions with each of the main effects were explored. RESULTS: : Of the 27,399 admissions, 21,500 had urine COC toxicology testing performed and were included in the study. COC was positive in 11.4% of the studied population. COC+ patients were significantly younger, with 72% of COC+ versus 43% of COC- in the 25 to 44 years age group. COC+ patients were more likely to be men, positive for alcohol, and intentional injury victims. COC+ status was not associated with subsequent suicide. Furthermore, the COC+ status association with subsequent homicide became nonsignificant after adjusting for confounders. Unadjusted COC+ status was associated with unintentional injury death (odds ratio = 1.65 [1.14-2.40]). Interactions were found in the association with unintentional injury death such that COC+ status tripled the odds of injury death (odds ratio = 2.75 [1.58-4.78]) among the alcohol-negative patients within the 25 to 45 years age group. CONCLUSION: : COC+ trauma patients are at an increased risk of subsequent unintentional injury death after discharge from a trauma center. Suicide and homicide occurrence seems to be unaffected.

Outcomes of cocaine-positive trauma patients undergoing surgery on the first day after admission.

BACKGROUND: Concerns regarding complications of cocaine use are frequently used to justify delaying procedures among patients with positive urine cocaine toxicology (UCT); however, there is no evidence to support this practice. We investigated whether UCT+ patients experience a worse outcome than UCT- patients when undergoing surgery on the first day after admission to a trauma center. METHODS: Files of adult trauma patients undergoing surgery during the first 24 hours after admission were selected from a trauma database. Patients without UCT testing were excluded. UCT+ and UCT- patients were compared in relation to mortality; length of stay; and the development of cardiac, infectious, and neurologic complications. Possible confounders were analyzed. Student's t test, Pearson's chi2 test, and Wilcoxon's statistics were used for analysis (alpha = 0.05). Multiple logistic regression models and Cox proportional hazard methods were used to adjust for possible confounders. RESULTS: Of the 3,477 patients studied, 13% (n = 465) tested positive for cocaine. UCT+ patients had a different age distribution were more likely to be male and to have penetrating injury and had lower Injury Severity Scores than UCT- patients. Outcomes were similar for mortality (3% vs. 4%), for the development of infectious (18% and 19%) and neurologic (2% vs. 1%) complications, and median length of stay (5 days vs. 5 days). Cardiac complications were lower among the UCT+ patients (3% vs. 6%). Multiple logistic regression and Cox proportional hazard revealed results similar to those from the univariate analysis. CONCLUSION: Outcomes after surgery during the first 24 hours after admission are not negatively affected by the presence of UCT+. An apparent protective effect of UCT+ status in the development of cardiac complications needs to be explained.

Hospital-based violence intervention programs work.

BACKGROUND: Hospital-based violence prevention programs have emerged at trauma centers nationwide; however, none has been thoroughly evaluated for effectiveness. Our Violence Intervention Program (VIP) conducted a prospective randomized control study to evaluate the effectiveness of intervention for repeat victims of violence. METHOD: Patients admitted between 1999 and 2001 for treatment of injuries inflicted by a violent act were identified. Repeat victims of violence on parole/probation were invited to join the study. Participants were given a history-gathering questionnaire and randomized into two groups. Cases (intervention [n = 56]) received intensive psychosocial follow-up services, family or group therapy, and assisted with substance abuse treatment. Controls (nonintervention [n = 44]) received standard medical treatment and follow-through in accordance with standard parole or probation procedures. RESULTS: There was no significant difference in the number of arrests in the two groups. The control group was three times more likely to be arrested for a violent crime, two times more likely to be convicted of any crime, and four times more likely to be convicted of a violent crime. The projected time of incarceration is significantly longer for the control group. Repeat violent criminal activity was significantly more evident in the control group. CONCLUSION: Significant differences exist between the VIP intervention and nonintervention groups in terms of the quantity and severity of criminal activity.

Drug and alcohol use among drivers admitted to a Level-1 trauma center.

The purpose of this research was to determine the incidence and prevalence of drug use, alcohol use, and the combination of drug and alcohol use among motor vehicle crash (MVC) victims admitted to a Level-1 trauma center. In a 90-day study, nearly two-thirds of trauma center admissions were victims of motor vehicle crashes. Blood and urine was collected from 168 MVC victims of whom 108 were identified as the driver in the crash. Toxicology results indicated that 65.7% of drivers tested positive for either commonly abused drugs or alcohol. More than half of the drivers tested positive for drugs (50.9%) other than alcohol, with one in four drivers testing positive for marijuana use. About one-third of those using drugs had also been drinking, but alcohol was detected in only 30.6% of all injured drivers. Within the total MVC patient pool, passenger drug/alcohol use was equivalent to the driver population; however, injured pedestrians had higher rates of alcohol only than other MVC victims. There were no significant differences in drug and alcohol use between MVCs and trauma admissions of other causes. Of the patients with positive toxicology results, less than half (42%) were referred for evaluation for substance abuse disorders.

Daily multidisciplinary rounds shorten length of stay for trauma patients.

PURPOSE: Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution's training mission. We hypothesized that daily multidisciplinary "discharge rounds" would improve patient flow and increase readiness. METHODS: A senior trauma center physician leads discharge rounds, focusing on each patient's plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit's discharge planner; the unit nursing staff; and physical, occupational, and speech therapists. RESULTS: Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. "Bypass" status-inability to accept admissions-has been virtually eliminated. This effect has been sustained. CONCLUSION: By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.