Community-Level Disadvantage of Adults With Firearm- vs Motor Vehicle-Related Injuries.

Importance: Motor vehicle crash (MVC) and firearm injuries are 2 of the top 3 mechanisms of adult injury-related deaths in the US. Objective: To understand the differing associations between community-level disadvantage and firearm vs MVC injuries to inform mechanism-specific prevention strategies and appropriate postdischarge resource allocation. Design, Setting, and Participants: This multicenter cross-sectional study analyzed prospectively collected data from the American College of Surgeons (ACS) Firearm Study. Included patients were treated either for firearm injury between March 1, 2021, and February 28, 2022, or for MVC-related injuries between January 1 and December 31, 2021, at 1 of 128 participating ACS trauma centers. Exposures: Community distress. Main outcome and Measure: Odds of presenting with a firearm as compared with MVC injury based on levels of community distress, as measured by the Distressed Communities Index (DCI) and categorized in quintiles. Results: A total of 62 981 patients were included (mean [SD] age, 42.9 [17.7] years; 42 388 male [67.3%]; 17 737 Black [28.2%], 9052 Hispanic [14.4%], 36 425 White [57.8%]) from 104 trauma centers. By type, there were 53 474 patients treated for MVC injuries and 9507 treated for firearm injuries. Patients with firearm injuries were younger (median [IQR] age, 31.0 [24.0-40.0] years vs 41.0 [29.0-58.0] years); more likely to be male (7892 of 9507 [83.0%] vs 34 496 of 53 474 [64.5%]), identified as Black (5486 of 9507 [57.7%] vs 12 251 of 53 474 [22.9%]), and Medicaid insured or uninsured (6819 of 9507 [71.7%] vs 21 310 of 53 474 [39.9%]); and had a higher DCI score (median [IQR] score, 74.0 [53.2-94.8] vs 58.0 [33.0-83.0]) than MVC injured patients. Among admitted patients, the odds of presenting with a firearm injury compared with MVC injury were 1.50 (95% CI, 1.35-1.66) times higher for patients living in the most distressed vs least distressed ZIP codes. After controlling for age, sex, race, ethnicity, and payer type, the DCI components associated with the highest adjusted odds of presenting with a firearm injury were a high housing vacancy rate (OR, 1.11; 95% CI, 1.04-1.19) and high poverty rate (OR, 1.17; 95% CI, 1.10-1.24). Among patients sustaining firearm injuries patients, 4333 (54.3%) received no referrals for postdischarge rehabilitation, home health, or psychosocial services. Conclusions and Relevance: In this cross-sectional study of adults with firearm- and motor vehicle-related injuries, we found that patients from highly distressed communities had higher odds of presenting to a trauma center with a firearm injury as opposed to an MVC injury. With two-thirds of firearm injury survivors treated at trauma centers being discharged without psychosocial services, community-level measures of disadvantage may be useful for allocating postdischarge care resources to patients with the greatest need.

Characteristics of Firearm Injury by Injury Intent: The Need for Tailored Interventions.

INTRODUCTION: While the U.S. has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies. METHODS: This was a multi-center prospective cohort study of patients treated for firearm-related injuries at 128 U.S. trauma centers from 3/2021-2/2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were utilized to characterize patient communities. RESULTS: 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted (SI) firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. SI firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger, Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness. CONCLUSIONS: Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological.

Firearm injuries in Missouri.

Firearm deaths continue to be a major public health problem, but the number of non-fatal firearm injuries and the characteristics of patients and injuries is not well known. The American College of Surgeons Committee on Trauma, with support from the National Collaborative on Gun Violence Research, leveraged an existing data system to capture lethal and non-lethal injuries, including patients treated and discharged from the emergency department and collect additional data on firearm injuries that present to trauma centers. In 2020, Missouri had the 4th highest firearm mortality rate in the country at 23.75/100,000 population compared to 13.58/100,000 for the US overall. We examined the characteristics of patients from Missouri with firearm injuries in this cross-sectional study. Of the overall 17,395 patients, 1,336 (7.7%) were treated at one of the 11 participating trauma centers in Missouri during the 12-month study period. Patients were mostly male and much more likely to be Black and uninsured than residents in the state as a whole. Nearly three-fourths of the injuries were due to assaults, and overall 7.7% died. Few patients received post-discharge services.

Firearm Injuries treated at Trauma Centers in the United States.

BACKGROUND: While firearm injuries and deaths continue to be a major public health problem, the number of non-fatal firearm injuries and the characteristics of patients is not well known. The American College of Surgeons (ACS) Committee on Trauma leveraged an existing data system to collect additional data on fatal and non-fatal firearm injuries presenting to trauma centers. This report provides an overview of this initiative and highlights the challenges associated with capturing actionable data on firearm-injured patients. METHODS: 128 trauma centers that are part of the ACS Trauma Quality Improvement Program (TQIP) collected data on individuals of any age arriving alive between March 1, 2021 and February 28, 2022 with a firearm injury. In addition to the standard data collected for TQIP, abstractors also extracted additional data specific to this study. We linked data from the Distressed Community Index (DCI) to patient records using zip code of residence. RESULTS: A total of 17,395 patients were included, with mean (SD) age of 30.2 (13.5) years, 82.5% were male and the majority were Black and non-Hispanic. The mean proportion of variables with missing data varied among trauma centers, with a mean of 20.7% missing data. Injuries occurred most commonly in homes (31.2%) or on the street (26.6%); 70.4% of injuries were due to assaults. Nearly one-third of patients were discharged from the ED, 25.9% were admitted directly to the operating room, 10.9% to the ICU; 5.9% died in the ED and 10.3% died overall during their course of care. Nearly two-thirds of patients lived in the two highest distressed categories of communities; only 7.5% lived in the least distressed quintile. CONCLUSIONS: Utilizing trauma center data can be a valuable tool to improve our knowledge of firearm injuries if clinical practices and documentation of patient risks and circumstances are standardized. LEVEL OF EVIDENCE: III Level, epidemiological.

Association between Trauma Center Type and Mortality for Injured Children with Severe Traumatic Brain Injury.

BACKGROUND: There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children. METHODS: We utilized Trauma Quality Improvement Program data from 2017-2020 to identify children with severe traumatic brain injury managed at level I and II state- or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata and traumatic brain injury heterogeneity. RESULTS: There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2% and 28.9% for pediatric, adult, and mixed trauma centers respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (OR 1.67; 95% CI: 1.30 - 2.13) compared to pediatric trauma centers. Male sex, self-pay insurance status, and interfacility transfers, motor vehicle, pedestrian/ cyclist and firearm injury mechanisms, presence of concomitant abdomen, lower extremity, or chest injuries, midline shift >5 mm within 24 hours, presence of age-adjusted hypotension and either pupil asymmetry or non-reactivity were all associated with a greater odds of death. Adjustment for trauma volume and subgroup analysis using a homogenous traumatic brain injury subgroup did not change the demonstrated associations. CONCLUSIONS: Our results suggest mortality was higher at adult trauma centers compared to mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children. LEVEL OF EVIDENCE: III; Type of study: Prognostic/ epidemiological.

Use of performance reports among trauma medical directors and programme managers in the American College of Surgeons' Trauma Quality Improvement Program: a qualitative analysis.

BACKGROUND: The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use. STUDY DESIGN: Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique. RESULTS: Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others' data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations. CONCLUSION: Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives.

Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: A propensity-matched analysis.

BACKGROUND: Pulmonary embolism (PE) is a leading cause of delayed mortality in patients with severe injury. While low-molecular-weight heparin (LMWH) is often favored over unfractionated heparin (UH) for thromboprophylaxis, evidence is lacking to demonstrate an effect on the occurrence of PE. This study compared the effectiveness of LMWH versus UH to prevent PE in patients following major trauma. METHODS: Data for adults with severe injury who received thromboprophylaxis with LMWH or UH were derived from the American College of Surgeons Trauma Quality Improvement Program (2012-2015). Patients who died or were discharged within 5 days were excluded. Rates of PE were compared between propensity-matched LMWH and UH groups. Subgroup analyses included patients with blunt multisystem injury, penetrating truncal injury, shock, severe traumatic brain injury, and isolated orthopedic injury. A center-level analysis was performed to determine if practices with respect to choice of prophylaxis type influence hospital PE rates. RESULTS: We identified 153,474 patients at 217 trauma centers who received thromboprophylaxis with LMWH or UH. Low-molecular-weight heparin was given in 74% of patients. Pulmonary embolism occurred in 1.8%. Propensity score matching yielded a well-balanced cohort of 75,920 patients. After matching, LMWH was associated with a significantly lower rate of PE compared with UH (1.4% vs. 2.4%; odds ratio, 0.56; 95% confidence interval, 0.50-0.63). This finding was consistent across injury subgroups. Trauma centers in the highest quartile of LMWH utilization (median LMWH use, 95%) reported significantly fewer PE compared with centers in the lowest quartile (median LMWH use, 39%; 1.2% vs. 2.0%; odds ratio, 0.59; 95% confidence interval, 0.48-0.74). CONCLUSIONS: Thromboprophylaxis with LMWH (vs. UH) was associated with significantly lower risk of PE. Trauma centers favoring LMWH-based prophylaxis strategies reported lower rates of PE. Low-molecular-weight heparin should be the anticoagulant agent of choice for prevention of PE in patients with major trauma. LEVEL OF EVIDENCE: Therapeutic study, level III.

Timing of Pharmacologic Venous Thromboembolism Prophylaxis in Severe Traumatic Brain Injury: A Propensity-Matched Cohort Study.

BACKGROUND: Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication. STUDY DESIGN: Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (<72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death. RESULTS: We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25-0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36-0.72), but no increase in risk of late neurosurgical intervention or death. CONCLUSIONS: In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.

The impact of short prehospital times on trauma center performance benchmarking: An ecologic study.

BACKGROUND: Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. METHODS: We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. RESULTS: During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. CONCLUSION: At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.

Good neighbors? The effect of a level 1 trauma center on the performance of nearby level 2 trauma centers.

OBJECTIVE: In this study, we sought to determine whether the proximity of a level 1 trauma center (TC) might affect the performance of a nearby level 2 TC. BACKGROUND: With the exception of research and teaching programs, level 2 TC must function at a level similar to that of level 1 TC, and provide high quality, definitive care to severely injured patients. However, the role of a level 2 TC within a region might vary significantly depending on the local trauma care environment. We postulated that the case mix, regional role and outcomes of level 2 TC are greatly influenced by the regional presence of a level 1 TC. METHODS: Data were derived from the National Trauma Databank (9.0), limiting to adults with Injury Severity Score ≥9. Level 2 TC were classified as either isolated trauma centers (ITC, >30 miles from the closest level 1 TC) or neighbored trauma centers (NTC, ≤30 miles from the closest level 1 TC). Regression was used to calculate risk-adjusted mortality at each center type. RESULTS: Fifty-five thousand six hundred and fifty-five patients were identified at 161 centers; 55% of patients were cared for at ITC (n = 84 centers). Case mix varied significantly across center type; in particular, ITC received significantly more transfer patients than NTC. After adjusting for differences in case mix, patients at ITC had a 12% lower risk of death than patients treated at NTC (0.88, 95% CI 0.78-0.98). CONCLUSIONS: Level 2 TC assume different roles depending on the local trauma system configuration. Ideally, a level 2 TC should benefit from the presence of a nearby level 1 TC through collaborations in care protocols and shared case reviews. However, these data suggest the opposite: level 2 centers in proximity to level 1 centers might perform at a lower than expected level.

Duplex ultrasound screening for deep vein thrombosis in asymptomatic trauma patients: a survey of individual trauma surgeon opinions and current trauma center practices.

BACKGROUND: Many national agencies have suggested that deep vein thrombosis (DVT) rates measure quality of hospital care. However, none provide recommendations for standardized screening. If screening practices vary among clinicians or hospitals, DVT rates could be biased-centers which perform more duplex ultrasounds report more DVTs. We hypothesized that trauma surgeons have varying opinions regarding duplex ultrasound screening for DVT in asymptomatic trauma patients, which result in varying practice patterns. METHODS: We conducted two web-based surveys regarding the use of duplex ultrasound screening for DVT in asymptomatic trauma patients. The first (individual provider level) surveyed members of two national trauma surgery organizations (American Association for the Surgery of Trauma and Eastern Association for the Surgery of Trauma). The second (trauma center level) surveyed practice patterns of National Trauma Data Bank hospitals. RESULTS: Three hundred seventeen individual surgeons completed surveys. There was wide variation in individual opinions regarding DVT screening in asymptomatic trauma patients (53% agree, 36% disagree, and 11% neither agree nor disagree). Two hundred thirteen National Trauma Data Bank hospitals completed surveys of which 28% (n=60) have a written guideline regarding DVT screening in asymptomatic trauma patients. The proportion of centers with a written protocol varied significantly by trauma center level (p<0.001) but not by teaching status. Opinions and practice patterns suggest that screening should start early and be performed weekly. The main risk factors used to suggest DVT screening are spinal cord injury and pelvic fracture. CONCLUSIONS: There are wide variations in trauma surgeons' opinions and trauma centers' practices regarding duplex ultrasound screening for DVT in asymptomatic trauma patients. This variability combined with the fact that performing more duplex ultrasounds finds more DVTs may influence reported DVT rates. DVT rates alone are biased and not reflective of true quality of trauma care.

The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility.

OBJECTIVE: The American College of Surgeons Committee on Trauma has created a "Trauma Quality Improvement Program" (TQIP) that uses the existing infrastructure of Committee on Trauma programs. As the first step toward full implementation of TQIP, a pilot study was conducted in 23 American College of Surgeons verified or state designated Level I and II trauma centers. This study details the feasibility and acceptance of TQIP among the participating centers. METHODS: Data from the National Trauma Data Bank for patients admitted to pilot study hospitals during 2007 were used (15,801 patients). A multivariable logistic regression model was developed to estimate risk-adjusted mortality in aggregate and on three prespecified subgroups (1: blunt multisystem, 2: penetrating truncal, and 3: blunt single-system injury). Benchmark reports were developed with each center's risk adjusted mortality (expressed as an observed-to-expected [O/E] mortality ratio and 90% confidence interval [CI]) and crude complication rates available for comparison. Reports were deidentified with only the recipient having access to their performance relative to their peers. Feedback from individual centers regarding the utility of the reports was collected by survey. RESULTS: Overall crude mortality was 7.7% and in cohorts 1 to 3 was 16.4%, 12.4%, and 5.1%, respectively. In the aggregate risk-adjusted analysis, three trauma centers were low outliers (O/E and 90% CI <1) and two centers were high outliers (O/E and 90% CI >1) with the remaining 18 centers demonstrating average mortality. Challenges identified were in benchmarking mortality after penetrating injury due to small sample size and in the limited capture of complications. Ninety-two percent of survey respondents found the report clear and understandable, and 90% thought that the report was useful. Sixty-three percent of respondents will be taking action based on the report. CONCLUSIONS: Using the National Trauma Data Bank infrastructure to provide risk-adjusted benchmarking of trauma center mortality is feasible and perceived as useful. There are differences in O/E ratios across similarly verified or designated centers. Substantial work is required to allow for morbidity benchmarking.