Estimating the effect of emergency care on early survival after traffic crashes

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

A case of a motor vehicle collision suspected as associated with development of angiosarcoma

Trauma has been suspected as a factor leading to development of angiosarcoma, a malignant soft-tissue tumor. We conducted a forensic autopsy to investigate a putative relation between a motor vehicle collision and the driver's later death from angiosarcoma. A vehicle operated by a man in his 60 s collided with an oncoming vehicle at a curve. The victim noticed no injury at the scene. However, 45 days later, he was transferred to an emergency room with dyspnea and bloody sputum. After diagnosis of angiosarcoma, he died of respiratory failure 132 days later. The bereaved family speculated about a relation between the collision and angiosarcoma onset. At autopsy, tumor cells of the scalp had metastasized to the lung, pleura, liver, and spleen. Histopathological examinations revealed characteristic features of angiosarcoma with positive immune-staining for CD31, CD34, and factor VIII. When a person dies some time after a collision, it is designated as a delayed death. In such cases, the relevance of trauma to the person's death is often an issue of concern. Because the interval between trauma and angiosarcoma development was short, only 45 days, the angiosarcoma might be coincidental. Therefore, we rejected the relation. Forensic experts sometimes need to investigate such inquiries.

Impact of Community Socioeconomic Characteristics on Emergency Medical Service Delays in Responding to Fatal Vehicle Crashes

Introduction

This study aimed to determine the impact of community socioeconomic status on emergency medical services' response time for fatal vehicle crashes.

Methods

Authors used the 2019 National Highway Traffic Safety Administration Fatality Analysis Reporting System and 2019-2020 Area Health Resource Files to obtain emergency medical services' time intervals and county socioeconomic characteristics (e.g., median household income, availability of trauma centers, and rurality), generating a study sample of 18,540 individuals involved in fatal vehicle crashes between January and December 2019. Generalized linear models with log-link and Gamma-family were used to obtain estimates, and other variables were adjusted in the model.

Results

Both the mean time of the emergency medical service arrival to the site of the crash and the mean transport time from the crash site to hospital varied by county SES. Counties with a higher mean household income had 12% shorter emergency medical services' arrival times and up to 7% shorter emergency medical services' hospital transport times than counties with lower SES. The emergency medical services' hospital transport times by emergency medical services also varied by proximity to trauma centers and were 15% shorter in counties that had ≥2 trauma centers than in counties without trauma centers.

Conclusions

This study shows socioeconomic disparities in emergency medical service rescue time for fatal vehicle crashes. Community characteristics play a major role in emergency medical services' arrival time intervals. Prior research demonstrated a strong link between the timeliness of emergency medical service response and the likelihood of survival in fatal motor vehicle accidents. These findings showing that socioeconomically disadvantaged areas and those lacking trauma facilities had slower emergency medical service rescue times, suggest that socioeconomic status may be a predictor of mortality in fatal motor vehicle accidents. Effective emergency medical services are essential to reduce the morbidity and mortality among motor vehicle crash victims; however, disparities exist in the timeliness of these services by geographic and socioeconomic county characteristics. Further research is urgently needed to inform policy interventions.

Machine learning-based injury severity prediction of level 1 trauma center enrolled patients associated with car-to-car crashes in Korea

Injury prediction models enables to improve trauma outcomes for motor vehicle occupants in accurate decision-making and early transport to appropriate trauma centers. This study aims to investigate the injury severity prediction (ISP) capability in machine-learning analytics based on five-different regional Level 1 trauma center enrolled patients in Korea. We study car crash-related injury data of 1417 patients enrolled in the Korea In-Depth Accident Study database from January 2011 to April 2021. Severe injury classification was defined using an Injury Severity Score of 15 or greater. A planar crash was considered by excluding rollovers to compromise an accurate prediction. Furthermore, dissimilarities of the collision partner component based on vehicle segmentation were assumed for crash incompatibility. To handle class-imbalanced clinical datasets, we used four data-sampling techniques (i.e., class-weighting, resampling, synthetic minority oversampling, and adaptive synthetic sampling). Machine-learning analytics based on logistic regression, extreme gradient boosting (XGBoost), and a multilayer perceptron model were used for the evaluations. Each model was executed using five-fold cross-validation to solve overfitting consistent with the hyperparameters tuned to improve model performance. The area under the receiver operating characteristic curve of 0.896. Additionally, the present ISP model showed an under-triage rate of 6.1%. The Delta-V, age, and Principal ~ were significant predictors. The results demonstrated that the data-balanced XGBoost model achieved a reliable performance on injury severity classification of emergency department patients. This finding considers ISP model selection, which affected prediction performance based on overall predictor variables.

Risk reduction via spatial and temporal visualization of road accidents: a way forward for emergency response optimization in developing countries

To achieve an effective emergency response and road safety, this study aims to assist a semi-automated dynamic system to analyze and predict the spatial distribution and temporal pattern of road crashes. Kasur, an intermediate city of Pakistan, was selected and data including location, time and reasons of accidents for five years (2014-2018) was utilized. Radar charts, Getis-Ord Gi* statistic, Moran's I spatial auto-correlation, and time series indices were engaged to present temporal, spatial and spatial-temporal variation of accidents, using python-based tools and jupyter notebook. A dynamic user interface was created using Github and Tableau to visualize a real-time zoom-able spatiotemporal variation of accidents. The results explain that out of 12 months, October faces the peak while April sees the least of road accidents. 7am is the peak hour for accidents and the weekends record a significantly higher number of road accidents as compared to weekdays. The city core witnesses the major hotspot areas with huge cluster of accidents. The findings contribute towards a well-informed decision support system, the knowledge of spatial analytics and its application in road safety science, and the preparedness of the rescue agencies for rapid response to reduce the impacts of road accidents.

Adapting SIMEX to correct for bias due to interval-censored outcomes in survival analysis with time-varying exposure

Many clinical and epidemiological applications of survival analysis focus on interval-censored events that can be ascertained only at discrete times of clinic visits. This implies that the values of time-varying covariates are not correctly aligned with the true, unknown event times, inducing a bias in the estimated associations. To address this issue, we adapted the simulation-extrapolation (SIMEX) methodology, based on assessing how the estimates change with the artificially increased time between clinic visits. We propose diagnostics to choose the extrapolating function. In simulations, the SIMEX-corrected estimates reduced considerably the bias to the null and generally yielded a better bias/variance trade-off than conventional estimates. In a real-life pharmacoepidemiological application, the proposed method increased by 27% the excess hazard of the estimated association between a time-varying exposure, representing the 2-year cumulative duration of past use of a hypertensive medication, and the hazard of nonmelanoma skin cancer (interval-censored events). These simulation-based and real-life results suggest that the proposed SIMEX-based correction may help improve the accuracy of estimated associations between time-varying exposures and the hazard of interval-censored events in large cohort studies where the events are recorded only at relatively sparse times of clinic visits/assessments. However, these advantages may be less certain for smaller studies and/or weak associations.

Understanding the role of faster emergency medical service response in the survival time of pedestrians

Fatalities and severe injuries among vulnerable road users, particularly pedestrians, are rising. In addition to the loss of life, about 6,000 annual pedestrian deaths in the U.S. cost society about $6 billion. Contrary to the assumption that all fatal pedestrian-involved crashes are similar, instantaneous death is substantially more severe than death that occurs several days after the crash. Instead of homogenizing all fatal pedestrian crashes, this study takes into account the severity of fatal injury crashes as a timeline based on the survival time of pedestrians. This study extracts valuable information from fatal crashes by examining pedestrians' survival time ranging from early death to death within 30 days of the crash. The Fatality Analysis Reporting System dataset is utilized from 2015 to 2018. The emergency medical service (EMS) response time is the key post-crash measure, while controlling for pedestrian, driver, roadway, and environmental characteristics. Notably, the response time and survival time can cause endogeneity, i.e., the response times may be shorter for more severe crashes. Due to the spatial and temporal nature of traffic crashes, to extract the association of different variables with pedestrians' survival time, a geographically and temporally weighted truncated regression with a two-stage residual inclusion treatment (local model) is estimated. The local model can overcome the endogeneity limitation (between EMS response time and survival time) and uncover the potentially spatially and temporally varying correlates of pedestrians' survival time with associated factors to account for unobserved heterogeneity. Moreover, to verify the variations are noticeable, a truncated regression with the two-stage residual inclusion treatment is developed (global model). The modeling results indicate that while capturing the unobserved heterogeneity, the local model outperformed the global model. The empirical results show that EMS response time, speeding, and some pedestrian behaviors are the most important factors that affect pedestrians' survival time in fatal injury crashes. However, the effect of factors on pedestrians' survival time is noticeably varied spatially and temporally. The results and their implications are discussed in detail in the paper.

Burn Center Referral Practice Evaluation and Treatment Outcomes Comparison Among Verified, Nonverified Burn Centers, and Nonburn Centers: A Statewide Perspective

The American Burn Association (ABA) has developed comprehensive referral criteria to determine which burn-injured patient should be transferred to burn centers. This was a retrospective analysis of burn injuries using Illinois inpatient and outpatient hospital data from 2010 to 2015. Multivariable logistic and linear regression models were developed to evaluate ABA burn center referral criteria adherence and to compare treatment outcomes among those treated in verified burn center (VB), nonverified burn center (NVB), and other facilities (OF). In this study, 66% of those treated in facilities without specialized burn teams met the ABA referral criteria. Patients who were older than the age of 40 years, lived farther from burn units, and were originally treated in level I trauma center without burn units were less likely to be transferred to burn centers. Those transported and treated in burn centers had overall better treatment outcomes including fewer infection complications (VB vs OF: adjusted odds ratio [aOR]: 0.5, 95% confidence interval [CI]: 0.4-0.6; NVB vs OF: aOR: 0.5, 95% CI: 0.4-0.6), fewer patients requiring additional care in skilled nursing/rehabilitation facilities (VB vs OF: aOR: 0.5, 95% CI: 0.4-0.6; NVB vs OF: aOR: 0.7, 95% CI: 0.6-0.9), shorter length of hospitalization (VB vs OF: β: -0.4, P < .001; NVB vs OF: β: -0.8, P < .001), and comparable in-hospital mortality (VB vs OF: aOR: 1.3, 95% CI: 0.97-1.7; NVB vs OF: aOR: 1.01, 95% CI: 0.7-1.5). While verified and unverified burn centers demonstrated better treatment outcomes, the data demonstrated a need to understand the barriers of adhering to ABA criteria and an improved regional burn center referral guidelines education.

A scoping review of worldwide studies evaluating the effects of prehospital time on trauma outcomes

BACKGROUND

Annually, over 1 billion people sustain traumatic injuries, resulting in over 900,000 deaths in Africa and 6 million deaths globally. Timely response, intervention, and transportation in the prehospital setting reduce morbidity and mortality of trauma victims. Our objective was to describe the existing literature evaluating trauma morbidity and mortality outcomes as a function of prehospital care time to identify gaps in literature and inform future investigation.

MAIN BODY

We performed a scoping review of published literature in MEDLINE. Results were limited to English language publications from 2009 to 2020. Included articles reported trauma outcomes and prehospital time. We excluded case reports, reviews, systematic reviews, meta-analyses, comments, editorials, letters, and conference proceedings. In total, 808 articles were identified for title and abstract review. Of those, 96 articles met all inclusion criteria and were fully reviewed. Higher quality studies used data derived from trauma registries. There was a paucity of literature from studies in low- and middle-income countries (LMIC), with only 3 (3%) of articles explicitly including African populations. Mortality was an outcome measure in 93% of articles, predominantly defined as "in-hospital mortality" as opposed to mortality within a specified time frame. Prehospital time was most commonly assessed as crude time from EMS dispatch to arrival at a tertiary trauma center. Few studies evaluated physiologic morbidity outcomes such as multi-organ failure.

CONCLUSION

The existing literature disproportionately represents high-income settings and most commonly assessed in-hospital mortality as a function of crude prehospital time. Future studies should focus on how specific prehospital intervals impact morbidity outcomes (e.g., organ failure) and mortality at earlier time points (e.g., 3 or 7 days) to better reflect the effect of early prehospital resuscitation and transport. Trauma registries may be a tool to facilitate such research and may promote higher quality investigations in Africa and LMICs.

Going to the nearest hospital vs. designated trauma centre for road traffic crashes: estimating the time difference in Delhi, India

Background: Time to hospital after a road traffic crash (RTC) plays a vital role in determining the outcome for crash victims. In Delhi, there are seven designated trauma centres where crash victims are typically taken, which may not be nearest hospital. We compare the transport time access (crash to hospital) depending on whether the victim is transported to a designated trauma centre or the nearest hospital. Data and methods: For each RTC geocoded manually from police records, the nearest hospital and the designated trauma centre is identified using Google Maps places nearby Search API and guidelines. Travel time matrix is generated between RTC's and identified hospitals using Google maps distance matrix API. Index accounting inter-district differences is developed. Results and conclusions: The network of designated trauma centres in New Delhi is located such that they can be accessed within 45 min of most crashes while nearest hospital within 30 min. As a result, the vast majority of crash victims are likely to receive timely care if they are rapidly transferred to either of these caregivers. However, for the most severely injured and time-sensitive cases, bypassing nearest hospital for trauma care, could substantially improve survival outcomes.

Trends in road transport collision deaths in the Irish paediatric population: a retrospective review of mortality data, 1991-2015

OBJECTIVE

To establish the incidence of road transport collision (RTC) fatalities in the Irish paediatric population, examining trends in fatality rates over a period of 25 years, during which several national road safety interventions were implemented.

STUDY DESIGN

Retrospective review of death registration details of children 0-19 years in Ireland between January 1991 and December 2015. Trends in mortality rates were investigated using average annual per cent change and Poisson regression analysis.

RESULTS

Proportionate RTC mortality, the majority of which occurred on public roads (94.1%, n=1432) increased with age; <0.3% (<1 year), 8.3% (1-14 years) and 18.4% (15-19 years) (2011-2015 average). Over time, rates declined significantly in all age groups; reductions of 79.0% (4.0 to 0.84/100 000, 1-14 years) and 68.4% (15.5 to 4.9/100 000, 15-19 years) resulted in 537 (95% CI 515 to 566) fewer child deaths (1-19 years) over the period 1996-2015. This reduction was evident for both road user types, the greatest decline (84.8%) among pedestrians 1-14 years (2.1 to 0.32/100 000) and the lowest (66.5%) among occupants 15-19 years, the majority of whom were male (12.4 to 4.2/100 000). The rate of decline was greatest during periods coinciding with introduction of targeted interventions. Risk of death in children 1-14 years was halved in the period after 2002 (incidence rate ratio (IRR) 0.52) while in children 15-19 years old, a significantly lower RTC fatality risk was evident after 2006 and 2010 (IRR 0.68 and IRR 0.50).

CONCLUSION

Child and adolescent mortality from RTCs has declined dramatically in Ireland, in excess of reductions in overall paediatric mortality. However, rates remain higher than in other EU countries and further effort is required to reduce the number of deaths further, particularly among adolescent males.

Who is responsible for global road safety? A cross-cultural comparison of Actor Maps

The traditional three 'E's approach to road safety (engineering, education, enforcement) has had, and will continue to have, a significant impact on road traffic casualty rates worldwide. Nevertheless, with rising motorisation in many countries, global fatality numbers have changed little over the past decade. Following calls for the application of sociotechnical systems thinking to the problem, we widen the road safety discussion with an additional four 'E's; economics, emergency response, enablement, and, the umbrella term for the approach taken, ergonomics. The research presents an application of Rasmussen's Risk Management Framework to the road safety systems of five distinct nations; Bangladesh, China, Kenya, the UK, and Vietnam. Following site visits, reviews of literature, and interviews with subject matter experts in each of the countries, a series of Actor Map models of the countries' road safety systems were developed. These are compared and discussed in terms of the wide variety of interconnecting organisations involved, their influences on road safety outcomes, the differences between nations, and the need to look beyond road users when designing road safety interventions.

R A Cowley, the “Golden Hour,” the “Momentary Pause,” and the “Third Space”

R Adams Cowley (1917–1991), the Baltimore thoracic and trauma surgeon, was an outstanding politician and promoter of emergency medical services. His skills included the effective use of language, for example, identifying the critical time immediately after injury as a “golden hour,” and describing shock as a “momentary pause in the act of death.” Conversely, Cowley avoided the tendency of some contemporaries to justify massive crystalloid infusion by invoking a “third space.” Cowley is often assumed to have originated the first two phrases, but, in fact, their histories go back at least to the 19th century and illustrate the development of surgical science. The “third space” is often assumed to have originated with Cowley's contemporary, Tom Shires (1925–2007), but, in fact, neither of them used the phrase to describe Shires’ controversial theories about an extracellular fluid deficit after trauma. Reviewing the actual etymology of these terms may help clarify the history of the underlying scientific ideas and enable more effective communication in the future.

Undertriage of Firearm-Related Injuries in a Major Metropolitan Area

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.

Evaluation of factors associated with the difficulty in finding receiving hospitals for traffic accident patients at the scene treated by emergency medical services: a population-based study in Osaka City, Japan

Aim

Although the prolongation of the time between injury and hospital arrival of traffic accident patients can influence their prognosis, factors associated with the difficulty in hospital acceptance of these patients have not been sufficiently evaluated in Japan.

Methods

We retrospectively analyzed the population‐based ambulance records of all traffic accident patients for whom the Osaka Municipal Fire Department (Osaka City, Japan) dispatched an ambulance in 2013. We defined “cases with difficulty in hospital acceptance” as cases that required ≥4 calls by emergency medical service personnel at the scene before receiving hospital acceptance. We included patient characteristics (age, sex, coma status, and trauma severity judged by emergency medical service personnel), time factors (day/night or weekday/holiday and weekends), and accident location for multivariable logistic regression analysis to assess factors associated with the difficulty in hospital acceptance.

Results

Among 13,427 traffic accident patients, 2,033 (15.1%) were cases with difficulty in hospital acceptance. Pediatric patients (adjusted odds ratio [OR], 1.265; 95% confidence interval [CI], 1.060–1.509), male sex (adjusted OR, 1.260; 95% CI, 1.135–1.398), moderate‐grade trauma (adjusted OR, 2.241; 95% CI, 1.972–2.547), severe‐grade trauma (adjusted OR, 2.057; 95% CI, 1.249–3.388), holidays and weekends (adjusted OR, 1.702; 95% CI, 1.539–1.882), and night‐time (adjusted OR, 2.720; 95% CI, 2.443–3.027) were positively associated with difficulty in hospital acceptance.

Conclusions

Using population‐based ambulance records from a large urban community in Japan, we showed that the difficulty in hospital acceptance of patients at the scene of traffic accidents was positively associated with several prehospital factors.

State-level geographic variation in prompt access to care for children after motor vehicle crashes

BACKGROUND

Motor vehicle crashes (MVCs) are a principal cause of death in children; fatal MVCs and pediatric trauma resources vary by state. We sought to examine state-level variability in and predictors of prompt access to care for children in MVCs.

MATERIALS AND METHODS

Using the 2010-2014 Fatality Analysis Reporting System, we identified passengers aged <15 y involved in fatal MVCs (crashes on US public roads with ≥1 death, adult or pediatric, within 30 d). We included children requiring transport for medical care from the crash scene with documented time of hospital arrival. Our primary outcome was transport time to first hospital, defined as >1 or ≤1 h. We used multivariable logistic regression to establish state-level variability in the percentage of children with transport time >1 h, adjusting for injury severity (no injury, possible injury, suspected minor injury, suspected severe injury, fatal injury, and unknown severity), mode of transport (emergency medical services [EMS] air, EMS ground, and non-EMS), and rural roads.

RESULTS

We identified 18,116 children involved in fatal MVCs from 2010 to 2014; 10,407 (57%) required transport for medical care. Median transport time was 1 h (interquartile range: [1, 1]; range: [0, 23]). The percent of children with transport time >1 h varied significantly by state, from 0% in several states to 69% in New Mexico. Children with no injuries identified at the scene and crashes on rural roads were more likely to have transport times >1 h.

CONCLUSIONS

Transport times for children after fatal MVCs varied substantially across states. These results may inform state-level pediatric trauma response planning.

Impact of trauma centre designation level on outcomes following hemorrhagic shock: a multicentre cohort study

BACKGROUND

Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS).

METHODS

We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS.

RESULTS

Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03-2.85) and 2.25 (1.08-4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II-IV centres than level I centres.

CONCLUSION

Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres.

What are the differences in injury patterns of young and elderly traffic accident fatalities considering death on scene and death in hospital?

Older traffic participants have higher risks of injury than the population up to 65 years in case of comparable road traffic accidents and further, higher mortality rates at comparable injury severities. Rib fractures as risk factors are currently discussed. However, death on scene is associated with hardly survivable injuries and might not be a matter of neither rib fractures nor age. As 60% of traffic accident fatalities are estimated to die on scene, they are not captured in hospital-based trauma registries and injury patterns remain unknown. Our database comprises 309 road traffic fatalities, autopsied at the Institute of Legal Medicine Munich in 2004 and 2005. Injuries are coded according to Abbreviated Injury Scale, AIS© 2005 update 2008 [1]. Data used for this analysis are age, sex, site of death, site of accident, traffic participation mode, measures of injury severity, and rib fractures. The injury patterns of elderly, aged 65+ years, are compared to the younger ones divided by their site of death. Elderly with death on scene more often show serious thorax injuries and pelvic fractures than the younger. Some hints point towards older fatalities showing less frequently serious abdominal injuries. In hospital, elderly fatalities show lower Injury Severity Scores (ISSs) compared to the younger. The number of rib fractures is significantly higher for the elderly but is not the reason for death. Results show that young and old fatalities have different injury patterns and reveal first hints towards the need to analyze death on scene more in-depth.

Evaluating the Potential Benefits of Advanced Automatic Crash Notification

OBJECTIVE

Advanced Automatic Collision Notification (AACN) services in passenger vehicles capture crash data during collisions that could be transferred to Emergency Medical Services (EMS) providers. This study explored how EMS response times and other crash factors impacted the odds of fatality. The goal was to determine if information transmitted by AACN could help decrease mortality by allowing EMS providers to be better prepared upon arrival at the scene of a collision.

METHODS

The Crash Injury Research and Engineering Network (CIREN) database of the US Department of Transportation/National Highway Traffic Safety Administration (USDOT/NHTSA; Washington DC, USA) was searched for all fatal crashes between 1996 and 2012. The CIREN database also was searched for illustrative cases. The NHTSA's Fatal Analysis Reporting System (FARS) and National Automotive Sampling System Crashworthiness Data System (NASS CDS) databases were queried for all fatal crashes between 2000 and 2011 that involved a passenger vehicle. Detailed EMS time data were divided into prehospital time segments and analyzed descriptively as well as via multiple logistic regression models.

RESULTS

The CIREN data showed that longer times from the collision to notification of EMS providers were associated with more frequent invasive interventions within the first three hours of hospital admission and more transfers from a regional hospital to a trauma center. The NASS CDS and FARS data showed that rural collisions with crash-notification times >30 minutes were more likely to be fatal than collisions with similar crash-notification times occurring in urban environments. The majority of a patient's prehospital time occurred between the arrival of EMS providers on-scene and arrival at a hospital. The need for extrication increased the on-scene time segment as well as total prehospital time.

CONCLUSION

An AACN may help decrease mortality following a motor vehicle collision (MVC) by alerting EMS providers earlier and helping them discern when specialized equipment will be necessary in order to quickly extricate patients from the collision site and facilitate expeditious transfer to an appropriate hospital or trauma center. Plevin RE , Kaufman R , Fraade-Blanar L , Bulger EM . Evaluating the potential benefits of advanced automatic crash notification. Prehosp Disaster Med. 2017;32(2):156-164.

Rural risk: Geographic disparities in trauma mortality

BACKGROUND

Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries.

METHODS

Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region.

RESULTS

Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P < .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P < .001), level II (odds ratio = 1.34, P < .001), and level IV/nontrauma centers (odds ratio = 1.23, P < .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P < .001 and odds ratio = 2.06, P < .001, respectively) and for cases with an injury severity score <9 or unknown severity (odds ratio = 2.09, P < .001 and odds ratio = 1.31, P < .001, respectively).

CONCLUSION

Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.

Importance of awareness in improving performance of emergency medical services (EMS) systems in enhancing traffic safety: A lesson from India

OBJECTIVE

India has been slow in implementing a central emergency medical services (EMS) system across the country. "108 services" is one of the most popular services that is functional under the public-private partnership model. Limited available literature shows that despite access to services, many traffic crash victims are transported using private vehicles. The objective of this study is to understand the effectiveness of 108 services from a traffic safety perspective.

METHOD

A questionnaire survey is conducted to understand the awareness of EMS and their function. Using traffic-related fatalities as the dependent variable, a fixed effect panel data model is developed to analyze the effectiveness of the 108 services in improving the traffic safety.

RESULTS

The results from the survey show that, in general, people are not aware of the 108 services. A majority of the population prefers taking victims to the hospital using their personal vehicles or any other vehicles available compared to calling an ambulance. Results from panel data analysis show that despite having an efficient system, these services failed to make significant improvement in the safety of road users in the states in which their services were subscribed.

DISCUSSION

The lack of awareness of an important safety service is alarming. This could be a major reason for lower utilization of 108 services for transporting victims of traffic crashes. This article shows the importance of having efficient awareness campaigns to improve the efficiency of any similar programs that are aimed to enhance the safety of a region.

Prehospital Emergency Medical Services Departure Interval: Does Patient Age Matter?

Introduction The concept of response time with minimal interval is intimately related to the practice of emergency medicine. The factors influencing this time interval are poorly understood. Problem In a process of improvement of response time, the impact of the patient's age on ambulance departure intervals was investigated.

METHOD

This was a 3-year observational study. Departure intervals of ambulances, according to age of patients, were analyzed and a multivariate analysis, according to time of day and suspected medical problem, was performed.

RESULTS

A total of 44,113 missions were included, 2,417 (5.5%) in the pediatric group. Mean departure delay for the adult group was 152.9 seconds, whereas it was 149.3 seconds for the pediatric group (P =.018).

CONCLUSION

A statistically significant departure interval difference between missions for children and adults was found. The difference, however, probably was not significant from a clinical point of view (four seconds). Schnegg B , Pasquier M , Carron PN , Yersin B , Dami F . Prehospital Emergency Medical Services departure interval: does patient age matter? Prehosp Disaster Med. 2016;31(6):608-613.

Isochrones as Indicators of the Influence of Traffic in Public Health: A Visual Simulation Application in Ávila, Spain

It is well known that excessive rescue times after traffic accidents negatively affect the health of those injured. There is a need to quantitatively measure the impact of unexpected events like ambulance availability, weather, floating population and congestion in those rescue times. A family of indicators based on isochrones is disguised and proposed to understand the risk of the whole population as the probability of not being assisted on time. Indicators of health risk for local towns are also defined. The indicators are calculated using a simulation model and visualized in web format. The framework of analysis is validated using Ávila (Spain) and the problem of the optimal deployment of ambulances as a test-bench.

Ambulance transport rates after motor vehicle collision for older vs. younger adults: a population-based study

Older adults are at greater risk than younger adults for life-threatening injury after motor vehicle collision (MVC). Among those with life-threatening injury, older adults are also at greater risk of not being transported by emergency medical services (EMS) to an emergency department. Despite the greater risk of serious injury and non-transportation among older adults, little is known about the relationship between patient age and EMS transportation rates for individuals experiencing MVC. We describe transport rates across the age-span for adults seen by EMS after experiencing MVC using data reported to the North Carolina Department of Motor Vehicles between 2008 and 2011. Of all adults aged 18 years and older experiencing MVC and seen by EMS (n=484,310), 36.3% (n=175,768) were transported to an emergency department. Rates of transport for individuals seen by EMS after MVC increased only a small amount with increasing patient age. After adjusting for potential confounders of the relationship between patient age and the decision to transport (patient gender, patient race, air bag deployment, patient trapped or ejected, and injury severity), transport rates were: age 18-64=36.0% (95% confidence interval [CI], 35.9-36.2%); age 65-74=36.6% (95% CI, 36.0-37.1%); age 75-84=37.3% (95% CI, 36.5-38.1%), and age 85-94=38.2% (95% CI, 36.7-39.8%). In North Carolina between 2008 and 2011, the transportation rate was only slightly higher for older adults than for younger adults, and most older adults experiencing MVC and seen by EMS were not transported to the emergency department. These findings have implications for efforts to improve the sensitivity of criteria used by EMS to determine the need for transport for older adults experiencing MVC.

The effect of hospital care on early survival after penetrating trauma

Background

The effectiveness of emergency medical interventions can be best evaluated using time-to-event statistical methods with time-varying covariates (TVC), but this approach is complicated by uncertainty about the actual times of death. We therefore sought to evaluate the effect of hospital intervention on mortality after penetrating trauma using a method that allowed for interval censoring of the precise times of death.

Methods

Data on persons with penetrating trauma due to interpersonal assault were combined from the 2008 to 2010 National Trauma Data Bank (NTDB) and the 2004 to 2010 National Violent Death Reporting System (NVDRS). Cox and Weibull proportional hazards models for survival time (t_SURV) were estimated, with TVC assumed to have constant effects for specified time intervals following hospital arrival. The Weibull model was repeated with t_SURV interval-censored to reflect uncertainty about the precise times of death, using an imputation method to accommodate interval censoring along with TVC.

Results

All models showed that mortality was increased by older age, female sex, firearm mechanism, and injuries involving the head/neck or trunk. Uncensored models showed a paradoxical increase in mortality associated with the first hour in a hospital. The interval-censored model showed that mortality was markedly reduced after admission to a hospital, with a hazard ratio (HR) of 0.68 (95% CI 0.63, 0.73) during the first 30 min declining to a HR of 0.01 after 120 min. Admission to a verified level I trauma center (compared to other hospitals in the NTDB) was associated with a further reduction in mortality, with a HR of 0.93 (95% CI 0.82, 0.97).

Conclusions

Time-to-event models with TVC and interval censoring can be used to estimate the effect of hospital care on early mortality after penetrating trauma or other acute medical conditions and could potentially be used for interhospital comparisons.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-014-0024-1) contains supplementary material, which is available to authorized users.

Opportunities for knowledge translation in the decade of road traffic safety

The United Nations has identified road traffic safety as an important objective for the decade 2011-2020. It has implemented a 5-tiered program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. A small body of practical research has been generated by the medical and surgical (including orthopaedic) communities regarding the road traffic safety, but a substantial amount of work remains to be performed. This article will review published research in each of the 5 tiers of the Decade of Action for Road Traffic Safety and will identify areas where research is insufficient or absent, such that new research programming and funding can be developed.