Association between intentional injury and long-term survival after trauma

Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database

BACKGROUND

Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission.

MATERIAL AND METHODS

This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted.

RESULTS

In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge.

CONCLUSION

27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.

Impact of novel psychosocial programming on readmission and recidivism rates among patients with violence-related trauma

INTRODUCTION

The Victims of Crime Advocacy and Recovery Program (VOCARP) provides advocacy, mental health resources, and educational materials. This study will report complications, readmissions, and recidivism among crime victims, and who used or did not use victim services.

MATERIALS AND METHODS

Patients engaged with programming from 3/1/17 until 12/31/18 were included. Control groups were patients injured by violent trauma without VOCARP use (N = 212) and patients injured by unintentional injuries (N = 201). Readmissions, complications, reoperations, and trauma recidivism were reported.

RESULTS

1019 patients (83%) used VOCARP. VOCARP users were less often male (56% vs. 71%), less commonly married (12% vs. 41%), and had fewer gunshot wounds (GSWs, 26% vs. 37%) and sexual assaults (4.1% vs. 8%), all p < 0.05. Of all 1,423 patients, 6.6% had a readmission and 7.4% developed a complication. VOCARP patients had fewer complications (4.5% vs. 13.7%), infections (2% vs. 9%), wound healing problems (1% vs. 3.3%), and deep vein thromboses (0.3% vs. 1.9%), all p < 0.05, but no differences in unplanned operations (4.5%). GSW victims had the most complications, readmissions, and unplanned surgeries. Prior trauma recidivism was frequent among all groups, with crime victim patients having 40% prior violence-related injury (vs 9.0% control, p < 0.0001). Trauma recidivism following VOCARP use occurred in 8.5% (vs 5.7% for non-users, p = 0.16).

CONCLUSION

Crime victims differ from other trauma patients, more often with younger age, single marital status, and unemployment at baseline. Complications were lower for VOCARP patients. GSW patients had the most complications, readmissions, and unplanned secondary procedures, representing a population for future attention.

Hospital-based violence prevention programmes in South Wales Emergency Departments: A process evaluation protocol

BACKGROUND

Addressing violence related harm is a global public health priority. While violence is primarily managed in the criminal justice system, healthcare supports and manages those injured by violence. Emergency Departments (EDs), the primary destination for those seriously injured, have emerged as a candidate location for violence prevention initiatives. There is limited evaluation of ED-based violence prevention, and a lack of guidance for the implementation and delivery of them. Nurse-led Violence Prevention Teams (VPTs) have been developed and implemented in two EDs in Wales, UK. This protocol describes methods used in the process evaluation of these VPTs.

AIM

To understand how VPTs function, how they were implemented, and mechanisms of impact, as well as the exploration of wider contextual factors influencing their function.

METHODS

Adopting a critical realist approach and informed by the Medical Research Council (MRC) guidance for process evaluations, the process evaluation will employ qualitative methods to collect and analyse data: a scoping review of evidence of effectiveness that considers the causal mechanisms underpinning violence; a documentary analysis to determine operational considerations concerning the development, implementation and delivery of the VPTs; a descriptive analysis of routine ED data to characterise the prevalence of violence-related attendances in each ED; interviews with professional stakeholders (N = 60) from the violence prevention ecologies in which the VPTs are embedded.

DISCUSSION

This protocol outlines a process evaluation of a novel, nurse led violence prevention intervention. Findings will be used to inform policy makers' decision making on whether and how VPTs should be used in practice in other EDs across the UK, and the extent that a single operational model should be adjusted to address the local characteristic of violence. To the authors knowledge, this is the first process evaluation of a UK-based, nurse led Emergency Department Violence Prevention Team.

TRIAL REGISTRATION

Protocol registration ISRCTN: 15286575. Registered 13th March, 2023.

The gap between hospital-based violence intervention services and client needs: A systematic review

BACKGROUND

Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs reduce reinjury. It is unclear how well they meet clients' reported needs. This systematic review aimed to quantify how well hospital-based violence intervention program services addressed clients' reported needs.

METHODS

Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing hospital-based violence intervention programs services and intentional injury survivors' needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, hospital-based violence intervention program services, and client needs assessments before and after receiving hospital-based violence intervention program services.

RESULTS

Of the 3,339 citations identified, 13 articles were selected for inclusion. Hospital-based violence intervention programs clients' most reported needs included mental health (10 studies), employment (7), and education (5) before receiving hospital-based violence intervention programs services. Only 4 studies conducted quantitative client needs assessments before and after receiving hospital-based violence intervention program services. All 4 studies were able to meet at least 50% of each of the clients' reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time-intensive long-term needs were least met, including employment 60% to 86% of clients, education 47% to 73%, and housing 50% to 71%.

CONCLUSION

Few hospital-based violence intervention programs studies considered clients' reported needs. Employment, education, and housing must be a stronger focus of hospital-based violence intervention programs.

Risk factors and predictors of violence: insights from the emergency department at a level 1 trauma center in the USA

BACKGROUND

This study aimed to assess the risk factors and predictors of violence among patients admitted to a Level 1 trauma center in a single institution.

METHODS

We conducted a retrospective analysis of patients who were admitted with a history of violence between 2012 and 2016.

RESULTS

A total of 9855 trauma patients were admitted, of whom 746 (7.6%) had a history of violence prior to the index admission. Patients who had history of violence were younger and more likely to be males, Black, Hispanic and covered by low-income primary payer in comparison to non-assault trauma patients (P < 0.001 for all). Multivariate logistic regression analysis showed that covariate-adjusted predictors of violence were being Black, male having low-income primary payer, Asian, drug user, alcohol intoxicated and smoker.

CONCLUSIONS

Violence is a major problem among young age subjects with certain demographic, social and ethnic characteristics. Trauma centers should establish violence injury prevention programs for youth and diverse communities.

Baseline Needs Assessment for a Hospital-Based Violence Intervention Program 1-Year Pilot

The objectives of the present study were to measure and describe the baseline participant needs of a hospital-based violence intervention 1-year pilot program, assess differences in expected hospital revenue based on changes in health insurance coverage resulting from program implementation and discuss the program’s limitations. Methods: Between September 2020 and September 2021 Encompass Omaha enrolled 36 participants. A content analysis of 1199 progress notes detailing points of contact with participants was performed to determine goal status. Goals were categorized and goal status was defined as met, in process, dropped, or participant refusal. Results: The most frequently identified needs were help obtaining short-term disability assistance or completing FMLA paperwork (86.11%), immediate financial aid (86.11%), legal aid (83.33%), access to food (83.3%), and navigating medical issues other than the primary reason for hospitalization (83.33%). Conclusions: Meeting the participants’ short-term needs is critical for maintaining their engagement in the long-term. Further, differences in expected hospital revenue for pilot participants compared with a control group were examined, and this analysis found a reduction in medical and facility costs for program participants. The pilot stage highlighted how complex the needs and treatment of victims of violence are. As the program grows and its staff become more knowledgeable about social work, treatment, and resource access processes, the program will continue to improve.

Comparing Firearm and Stabbing Injuries in the Pediatric Trauma Population Using Propensity Matching

OBJECTIVES

The objective of this study was to compare differences in mortality and nonhome discharge in pediatric patients with firearm and stab injuries, while minimizing bias. Our secondary objective was to assess the influence of insurance on these same outcomes.

METHODS

Patients aged 0 to 17 years included in the National Trauma Data Bank (2007-2015) with firearm and stabbing injury were matched by propensity score. Logistic regression was used to assess associations of injury type and insurance with long-term care discharge and death.

RESULTS

The average age was 14.8 years, 19.2% were female, 48% were African American, 58.4% had an injury severity score ≤8, and assaults accounted for 73.1% of cases. Firearm injuries were associated with a higher risk of discharge to long-term care (adjusted odds ratio [aOR], 2.07) compared with propensity-matched patients who were stabbed. Similarly, we found a higher risk of mortality in those with firearm injuries compared with stabbing injuries (aOR, 1.85). Regardless of mechanism, self-pay insurance status was associated with a higher risk of mortality (aOR, 2.41). When compared with stab wound patients with commercial insurance, self-pay firearm-injured patients were found to have an increased risk of mortality (aOR, 5.25).

CONCLUSIONS

Pediatric victims of firearm violence were more likely to die or need additional care outside the home than victims of other types of penetrating injury when accounting for confounding characteristics to minimize bias.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients

BACKGROUND

Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients.

METHODS

Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury.

RESULTS

Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study.

CONCLUSION

The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states.

LEVEL OF EVIDENCE

Economic and Value Based Evaluations; level III.

Causes of death following discharge after trauma in North Carolina

BACKGROUND

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission.

METHODS

This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis.

RESULTS

Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days).

CONCLUSION

After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level IV.

Implementation of programming for survivors of violence-related trauma at a level 1 trauma center

Background

Prior investigation of violence intervention programs has been limited. This study will describe resources offered by Victims of Crime Advocacy and Recovery Program (VOCARP), their utilization, and effect on recidivism.

Methods

VOCARP was established in 2017 at our center, and all patients who engaged with programming (n=1019) were prospectively recorded. Patients are offered services in the emergency department, on inpatient floors and at outpatient clinic visits. Two control groups (patients sustaining violent injuries without VOCARP use (n=212) and patients with non-violent trauma (n=201)) were similarly aggregated.

Results

During 22 months, 96% of patients accepted education materials, 31% received financial compensation, 27% requested referrals, and 22% had crisis interventions. All other resources were used by <20% of patients. Patients who used VOCARP resources were substantially different from those who declined services; they were less often male (56% vs. 71%), more often single (79% vs. 51%), had greater unemployment (63% vs. 51%) and were less frequently shot (gunshot wound: 26% vs. 37%), all p<0.05. Overall recidivism rate was 9.4%, with no difference between groups. Use of mental health services was linked to lower recidivism rates (4.4% vs. 11.7%, p=0.016). While sexual assault survivors who used VOCARP resources had lower associated recidivism (2.4% vs. 12%, p=0.14), this was not statistically significant.

Discussion

This represents the largest violence intervention cohort reported to date to our knowledge. Despite substantial engagement, efficacy in terms of lower recidivism appears limited to specific subgroups or resource utilization.

Level of evidence

Level II. Therapeutic.

Evaluation of Injury Recidivism Using the Electronic Medical Record

BACKGROUND

Traumatic injuries remain one of the leading causes of death in the United States. Patients who survive traumatic injuries but return to the emergency department with repeat injuries are said to suffer from injury recidivism. Numerous studies have described trends in injury recidivism using trauma registry and survey data. To our knowledge, no prior study has leveraged electronic medical record (EMR) data to characterize injury recidivism. The EMR is potentially more comprehensive as it contains details of patients who visited the emergency department after injury but did not meet the criteria for inclusion in the trauma registry. Such injuries could be predictive of future recidivism. We therefore aimed to describe patterns of injury recidivism seen at a Level 1 trauma center using the EMR.

METHODS

A retrospective review was conducted of all injury-related encounters between January 2016 and December 2019. Manual review was conducted of all recidivistic encounters with < 11 months between encounters to ensure the recidivistic encounter was not a sequela of the index visit. A general estimating equation logistic regression adjusted for age, race, sex, and insurance payor, estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between injury mechanism and odds of recidivistic encounter.

RESULTS

A total of 20,566 index encounters was included during the study period. Of the 20,566 encounters, 7.6% (n = 1570) had a recidivistic encounter during the study period, half of which (n = 781) occurred within the first year of the index encounter. An over two-fold increased odds of recidivism was observed for blunt assault encounters (OR 2.53, 95% CI 2.03-3.15) and unintentional falls (OR 2.10, 95% CI 1.76-2.52). For both mechanisms, this increase was observed across the three years following the index encounter.

CONCLUSIONS

Our study found that patients with assault injuries have the highest odds of injury recidivism and assault-related recidivistic encounters. These results demonstrate the feasibility and utility of incorporating EMR data, and suggest that the development of targeted interventions focused on mitigating assault injuries, such as hospital-based violence intervention programs, should be considered in our region.

Tourniquets as a haemorrhage control measure in military and civilian care settings: An integrative review

AIMS AND OBJECTIVES

The aim of review was to describe and synthesise the evidence on the use of tourniquets to control haemorrhages, summarising both civilian and military use.

BACKGROUND

Trauma-related haemorrhage constitutes one of the most preventable deaths among injured patients, particularly in multi-casualty incidents and disasters. In this context, safe instruments such as tourniquets are essential to help healthcare professionals to minimise loss of life and maximise patient recovery.

DESIGN AND METHODS

An integrative review was conducted in Medline, Nursing & Allied Health Premium, and Health & Medical Collection, using published data until March 2021 and following the PRISMA guidelines.

RESULTS

A total of 25 articles were included. Evidence has been synthesised to understand the use of different types of tourniquets, environment of application, indication for their placement and potential complications associated with tourniquet placement.

CONCLUSIONS

Commercial tourniquets such as Combat Application Tourniquet or Emergency Tourniquet models are a valuable and safe instrument for haemorrhage control in both military and civilian out-of-hospital care settings. Nurses, as part of emergency teams, and other professionals should be aware that there is a possibility of adverse complications, but they are directly proportional to the time of tourniquet placement and generally temporary. In addition, national and international guidelines ensure the need for all civilian emergency services to be equipped with these devices, as well as for the training of healthcare professionals and first responders in their use.

RELEVANCE TO CLINICAL PRACTICE

Despite the lack of complications in the use of tourniquets in these cases, their use has been a matter of debate for decades. In this sense, this review yields up-to-date guidelines in the use of tourniquets, their recommendations and their significance among professionals to manage complicated situations.

Does Level of Blood Alcohol Content Affect Clinical Outcomes After Trauma in Older Adult Patients?

INTRODUCTION

Preinjury alcohol use and older age have independently been associated with poor outcomes. This study examined whether higher levels of blood alcohol concentration (BAC) correlated with an increased likelihood of poor outcomes in older trauma patients.

METHODS

This was a retrospective cohort study of injured patients ≥65 years with BAC testing presenting to a Level 1 trauma center between 2015 and 2018. Patients were stratified by BAC at 4 thresholds of intoxication: BAC ≧10 mg/dL, BAC ≧80 mg/dL, BAC ≧150 mg/dL, and BAC ≧200 mg/dL. Propensity score matching using inverse probability of treatment weighting was used to estimate outcomes. Logistic and Poisson regression models were performed for each threshold of the BAC level with the matched cohort to assess clinical outcomes.

RESULTS

Of all older patients (n = 3112), 32.5% (n = 1012) had BAC testing. In the matched cohort of 883 patients (76.7 ± 8.2 years; 48.1% female), 111 (12.5%) had BAC ≧10 mg/dL, 83 (74.8%) had BAC ≧80 mg/dL, 60 (54.1%) had BAC ≧150 mg/dL, and 37 (33.3%) had BAC ≧200 mg/dL. Falls (60.5%) and motor vehicle crashes (28.9%) were the most common mechanisms of injury. Median (IQR) of Injury Severity Score (ISS) was 5 (1-10). The risk of severe injury (ISS ≧15) was similar between alcohol-positive and alcohol-negative patients (9.9% vs 15.0%, P = .151). BAC ≧10 g/dL was not associated with length of stay, intensive care unit admission, or in-hospital complication, nor was any of the other 3 analyzed BAC thresholds.

CONCLUSION

Overall, any detectable BAC along and increasing thresholds of BAC was not associated with poor in-hospital outcomes of older patients after trauma. Alcohol screening was low in this population, and intoxication may bias injury assessment, leading to mistriage of older trauma patients.

Death and long-term disability after gun injury: a cohort analysis

BACKGROUND

Gun injury accounts for substantial acute mortality worldwide and many others survive with lingering disabilities. We investigated whether additional health losses beyond mortality can also arise for patients who survive with long-term disability.

METHODS

We conducted a population-based individual patient analysis of adults injured by firearms who had received emergency medical care in Ontario, Canada, from Apr. 1, 2002, to Apr. 1, 2019. Longitudinal cohort analyses were evaluated through deterministic linkages of individual electronic patient files. The primary outcome was death or subsequent application for long-term disability in the years after hospital discharge.

RESULTS

In total, 8313 patients were injured from firearms, of which 3020 were injured from intentional incidents and 5293 were injured from unintentional incidents. A total of 2657 (88.0%) patients with intentional gun injury and 5089 (96.1%) patients with unintentional gun injury survived initial injuries. After a mean 7.75 years of follow-up, patients surviving intentional injuries had a disability rate twice as high as patients surviving unintentional injuries (19.7% v. 10.1%, p < 0.001), equivalent to a hazard ratio of 2.01 (95% confidence interval 1.80-2.25). The higher risk of long-term disability for survivors after intentional gun injury was not explained by demographic characteristics, extended to survivors treated and released from the emergency department, and was observed regardless of whether the incident was self-inflicted or from interpersonal assault. Half of the disability cases were identified after the first year. Additional predictors of long-term disability included a lower socioeconomic status, an urban home location, arrival by ambulance transport, a history of mental illness and a diagnosis of substance use disorder.

INTERPRETATION

Our study shows that gun death statistics underestimate the extent of health losses from long-term disability, particularly for those with intentional injuries. Additional and sustainable follow-up medical care might improve patient outcomes.

Are ED-based violence intervention programmes effective in reducing revictimisation and perpetration in victims of violence? A systematic review

OBJECTIVES

Community violence bears significant human and economic costs. Furthermore, victims requiring ED treatment are at a greater risk of violent reinjury, arrest due to perpetration and violent death. We aimed to evaluate the effectiveness of ED-based violence intervention programmes (EVIPs), which aim to reduce future violence involvement in these individuals.

METHODS

We performed a systematic literature review searching MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, The Cochrane Library and Web of Science, in addition to hand-searching. Randomised controlled trials (RCTs) were included if they enrolled victims of community violence requiring ED treatment, evaluated interventions taking place in the ED and used violent revictimisation, arrests or intermediate outcome measures as endpoints. We included trials that had a Jadad score of 2 or above.

RESULTS

297 records were identified, and 13 articles were included in our final qualitative analysis, representing 10 RCTs and 9 different EVIPs. The risk of selection bias was low; the risk of performance, detection and attrition bias was moderate. 9 out of 13 papers reported statistically significant improvements in one or more outcome measures related to violence, including violent reinjury and arrests due to violence perpetration.

CONCLUSION

The results of this literature review show that EVIPs may be capable of reducing violent reinjury and arrests due to violence perpetration. Larger RCTs, taking place in different regions, in different age groups and using different techniques, are justified to determine which conditions may be required for success and whether EVIPs are generalisable.

Higher Risk of Mortality in Intentional Traumatic Injuries; A Multivariate Regression Analysis of a Trauma Registry

OBJECTIVES

To assess whether intentional traumatic injuries are associated with higher mortality rate when compared to unintentional injuries.

METHODS

Data from SweTrau (Swedish National Trauma Registry). Information regarding age, gender, injury severity score (ISS), new injury severity score (NISS), Glasgow coma scale (GCS), systolic blood pressure, and respiratory rate were collected via "SweTrau". "Mortality within 30 days of injury" was defined as having been registered as dead within 30 days following the injury. Intentional injuries compared to non-intentional injuries. Multivariate regression analysis was conducted. Stepwise forward and backward regression was conducted.

RESULTS

A total number of 3875 patients were included. There were 3613 (93%) non-intentional and 262 (7%) intentional patients. The 30-day mortality rate was higher in the intentional group compared to non-intentional group, 10% vs. 4% (p<0.001). Patients in the intentional group were younger than the non-intentional group, at 39±18 vs. 47±21 years old (p<0.001). In both, the forward and backward tests injury intention remained statistically significant with OR 2 (CI 1.1-3.7). Shock (OR 4.7, CI 2.9-7.8), Severe Head Injury (OR 8.9, CI 5.3-14.7), Age ≥ 60 (OR 6.7, CI 4.1-10.8), ISS ≥16 (OR 10.8, CI 6.9-16.9) and ASA (OR 3.5, CI 2.2-5.7) were other factors affecting mortality.

CONCLUSION

Injury intention was an independent factor contributing to mortality in our study. This particular cohort needs further attention during trauma management with a holistic insight to improve their survival.

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases

OBJECTIVES

Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

METHODS

We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

RESULTS

Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

CONCLUSIONS

Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

One-year and three-year mortality prediction in adult major blunt trauma survivors: a National Retrospective Cohort Analysis

Background

Survivors of trauma are at increased risk of dying after discharge. Studies have found that age, head injury, injury severity, falls and co-morbidities predict long-term mortality. The objective of our study was to build a nomogram predictor of 1-year and 3-year mortality for major blunt trauma adult survivors of the index hospitalization.

Methods

Using data from the Singapore National Trauma Registry, 2011–2013, we analyzed adults aged 18 and over, admitted after blunt injury, with an injury severity score (ISS) of 12 or more, who survived the index hospitalization, linked to death registry data. The study population was randomly divided 60/40 into separate construction and validation datasets, with the model built in the construction dataset, then tested in the validation dataset. Multivariable logistic regression was used to analyze 1-year and 3-year mortality.

Results

Of the 3414 blunt trauma survivors, 247 (7.2%) died within 1 year, and 551 (16.1%) died within 3 years of injury. Age (OR 1.06, 95% CI 1.05–1.07, p < 0.001), male gender (OR 1.53, 95% CI 1.12–2.10, p < 0.01), low fall from 0.5 m or less (OR 3.48, 95% CI 2.06–5.87, p < 0.001), Charlson comorbidity index of 2 or more (OR 2.26, 95% CI 1.38–3.70, p < 0.01), diabetes (OR 1.31, 95% CI 1.68–2.52, p = 0.04), cancer (OR 1.76, 95% CI 0.94–3.32, p = 0.08), head and neck AIS 3 or more (OR 1.79, 95% CI 1.13–2.84, p = 0.01), length of hospitalization of 30 days or more (OR 1.99, 95% CI 1.02–3.86, p = 0.04) were predictors of 1-year mortality. This model had a c-statistic of 0.85. Similar factors were found significant for the model predictor of 3-year mortality, which had a c-statistic of 0.83. Both models were validated on the second dataset, with an overall accuracy of 0.94 and 0.84 for 1-year and 3-year mortality respectively.

Conclusions

Adult survivors of major blunt trauma can be risk-stratified at discharge for long-term support.

Surgical deserts in California: an analysis of access to surgical care

BACKGROUND

Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.

METHODS

We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.

RESULTS

There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.

CONCLUSIONS

Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

Pregnant trauma victims experience nearly 2-fold higher mortality compared to their nonpregnant counterparts

BACKGROUND

Trauma is the leading nonobstetric cause of death in women of reproductive age, and pregnant women in particular may be at increased risk of violent trauma. Management of trauma in pregnancy is complicated by altered maternal physiology, provider expertise, potential disparate imaging, and distorted anatomy. Little is known about the impact of trauma on maternal mortality.

OBJECTIVE

We sought to: (1) characterize nonviolent and violent trauma among pregnant women; (2) determine whether pregnancy is associated with increased mortality following traumatic injury; and (3) identify risk factors for trauma-related death in pregnant women.

STUDY DESIGN

We studied 1148 trauma events among pregnant girls and women and 43,608 trauma events among nonpregnant girls and women of reproductive age (14-49 years) who presented to any accredited trauma center in Pennsylvania for treatment of trauma-related injuries from 2005 through 2015, as captured in the Pennsylvania Trauma Outcome Study. Traumas were categorized as violent (eg, homicide or assault) or nonviolent (eg, motor vehicle accident or accidental fall). We used modified Poisson regression to estimate relative rate of trauma-related death, adjusting for demographic characteristics and severity of trauma.

RESULTS

Compared to nonpregnant women, pregnant women and girls had a lower injury severity score (8.9 vs 10.9, P < .001) and were significantly more likely to experience violent trauma (15.9% vs 9.8%, P < .001). Pregnant trauma victims had a 1.6-fold higher rate of mortality compared to their nonpregnant counterparts (P < .001), and were both more likely to be dead on arrival and to die during their hospital course (adjusted relative risk, 2.33, P < .001, and adjusted relative risk, 1.79, P = .004, respectively). Pregnancy was associated with increased mortality in both victims of nonviolent and violent trauma (adjusted relative risk, 1.69, P = .002, and adjusted relative risk, 1.60, P = .007, respectively). Pregnant trauma victims were less likely to undergo surgery (adjusted relative risk, 0.70, P = .001) and more likely to be transferred to another facility (adjusted relative risk, 1.72, P < .001). Even after adjusting for demographics and injury severity score, violent trauma was associated with 3.14-fold higher mortality in pregnant women and girls compared to nonviolent trauma (adjusted relative risk, 3.14, P = .003).

CONCLUSION

Pregnant women and girls are nearly twice as likely to die after trauma and twice as likely to experience violent trauma. Universal screening for violence and trauma during pregnancy may provide an opportunity to identify women at risk for death during pregnancy.

A decade of hospital-based violence intervention: Benefits and shortcomings

INTRODUCTION

Initial analyses of hospital-based violence intervention programs (VIPs) have demonstrated decreased violent injury recidivism. Long-term VIP performance has not been assessed. Violence intervention program quality improvement requires evaluation to identify shortcomings and client subpopulations warranting additional resources. We evaluated our case manager-based VIPs to identify modifiable risk factors that most impact violent injury recidivism and determine subpopulations that need modification of targeted services.

METHODS

Data on demographic variables, socioeconomic factors, needs, and injury recidivism from 2005 to 2014 were collected through our VIP database. Possible client needs included housing, education, employment, court advocacy, driver's license obtainment, and "other." Case managers assessed needs as "not needed," "identified (unmet)," and "met." χ And nonparametric tests were used to identify factors associated with recidivism reduction.

RESULTS

Over the 10-year period, 466 clients were enrolled in VIP. During the program period, the violent reinjury rate was 4%, as compared with a historical control of 8% from 2000 to 2004. Women had lower rates of reinjury than men (3% vs 13%, respectively, p = 0.023). Blacks had the lowest recidivism (2%, p < 0.0001), whereas a higher rate (11%) was observed among Latinos. Although a minority of clients (5%), 100% of white clients were reinjured. Mental health services (51%), victim-of-crime compensation (48%), employment (36%), and housing (30%) were the most frequently identified needs. Expressing the need for education was significantly associated with likelihood of reinjury, an effect that was completely reversed when the need was met.

CONCLUSION

This evaluation of a VIP demonstrates sustained recidivism reduction and success in addressing client needs from a traditionally underserved population. Efforts to identify and address root causes of Latino and white client reinjury should be increased. Violence intervention program prioritization of housing needs may reduce future reinjury. This study demonstrating sustainable success underscores the importance of increased integration of VIP into trauma centers nationally.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Trauma Recidivism Predicts Long-term Mortality: Missed Opportunities for Prevention (Retrospective Cohort Study)

OBJECTIVES

The objectives of this study were to determine the association between recurrent trauma admissions (recidivism) and subsequent long-term mortality, and to identify those in most need for preventive interventions.

BACKGROUND

Patients with a single intentional injury have been shown to have a higher risk of future injury mortality than those with unintentional injury with 5-year mortality rates as high as 20% being reported for recurrent penetrating trauma. Trauma recidivism identifies a high-risk population, but its association with long-term mortality is largely unknown.

METHODS

Patients with 1 or more previous admissions to an urban trauma center (recidivists) were identified and compared with those with single admissions (nonrecidivists) from 1997 to 2008. The trauma registry was linked to the National Death Index to determine both the cause and time to death after hospital discharge. Statistical analysis included chi-square tests, Kaplan-Meier survival curves, and Cox proportional-hazards models.

RESULTS

Trauma recidivists were 7% of the total trauma population from 1997 to 2008, representing 3147 patients. Recidivists were more likely to be male (P < 0.0001), Black (P < 0.0001), have a blood alcohol content above 80 mg/dL (P < 0.0001), and suffer a penetrating injury (P < 0.0001) compared with nonrecidivists. Recidivists with both initial blunt and penetrating injuries had higher rates of long-term mortality after discharge. Recidivists were more likely to die of any cause based on Cox proportional-hazard ratios [hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.57-2.01], injury death (HR 2.02, 95% CI 1.66-2.47), and disease death (HR 1.65, 95% CI 1.41-1.92) than nonrecidivists.

CONCLUSIONS

Male sex, Black race, and elevated blood alcohol content and penetrating injury are associated with trauma recidivism which leads to a higher risk of death. There is a critical public health need to develop interventions to reduce trauma recidivism and preventable death.

Trauma Center Based Youth Violence Prevention Programs: An Integrative Review

OBJECTIVE

Youth violence recidivism remains a significant public health crisis in the United States. Violence prevention is a requirement of all trauma centers, yet little is known about the effectiveness of these programs. Therefore, this systematic review summarizes the effectiveness of trauma center-based youth violence prevention programs.

METHODS

A systematic review of articles from MEDLINE, CINAHL, and PsychINFO databases was performed to identify eligible control trials or observational studies. Included studies were from 1970 to 2013, describing and evaluating an intervention, were trauma center based, and targeted youth injured by violence (tertiary prevention). The social ecological model provided the guiding framework, and findings are summarized qualitatively.

RESULTS

Ten studies met eligibility requirements. Case management and brief intervention were the primary strategies, and 90% of the studies showed some improvement in one or more outcome measures. These results held across both social ecological level and setting: both emergency department and inpatient unit settings.

CONCLUSIONS

Brief intervention and case management are frequent and potentially effective trauma center-based violence prevention interventions. Case management initiated as an inpatient and continued beyond discharge was the most frequently used intervention and was associated with reduced rearrest or reinjury rates. Further research is needed, specifically longitudinal studies using experimental designs with high program fidelity incorporating uniform direct outcome measures. However, this review provides initial evidence that trauma centers can intervene with the highest of risk patients and break the youth violence recidivism cycle.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality

BACKGROUND

Racial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center.

METHODS

We conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models.

RESULTS

There were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62).

CONCLUSIONS

Although rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

Causes of excessive late death after trauma compared with a matched control cohort

BACKGROUND

Studies on mortality following trauma have been restricted mainly to in-hospital or 30-day death. Mortality risk may be sustained several years after trauma, but the causes of late death have not been elucidated. The aim was to investigate mortality and analyse causes of late death after trauma.

METHODS

All injured patients from a regional trauma registry with long-term follow-up were matched in a 1 : 5 ratio with uninjured controls by age, sex and municipality. By linkage to national registries, long-term mortality, causes of death and co-morbidity status were identified. Excess mortality was examined by calculating the all-cause mortality rate ratio (MRR).

RESULTS

Among the trauma cohort of 7382 patients, 662 (9·0 per cent) died within 3 years after the index trauma; the 30-day mortality rate was 5·0 per cent. Compared with the control group (36 759 individuals), there was a sustained increase in mortality up to 3 years after trauma; the MRR was 2·88 (95 per cent c.i. 2·37 to 3·50) for days 31-365, 1·59 (1·24 to 2·04) for years 1-2 and 1·43 (1·06 to 1·92) for years 2-3. External causes, including new trauma, were far more common causes of late death in injured patients than in matched controls.

CONCLUSION

Postinjury mortality is increased for several years after trauma. Excess mortality is largely attributed to recurrent trauma and other external causes of death.

Cost-benefit analysis simulation of a hospital-based violence intervention program

BACKGROUND

Violent injury is a major cause of disability, premature mortality, and health disparities worldwide. Hospital-based violence intervention programs (HVIPs) show promise in preventing violent injury. Little is known, however, about how the impact of HVIPs may translate into monetary figures.

PURPOSE

To conduct a cost-benefit analysis simulation to estimate the savings an HVIP might produce in healthcare, criminal justice, and lost productivity costs over 5 years in a hypothetical population of 180 violently injured patients, 90 of whom received HVIP intervention and 90 of whom did not.

METHODS

Primary data from 2012, analyzed in 2013, on annual HVIP costs/number of clients served and secondary data sources were used to estimate the cost, number, and type of violent reinjury incidents (fatal/nonfatal, resulting in hospitalization/not resulting in hospitalization) and violent perpetration incidents (aggravated assault/homicide) that this population might experience over 5 years. Four different models were constructed and three different estimates of HVIP effect size (20%, 25%, and 30%) were used to calculate a range of estimates for HVIP net savings and cost-benefit ratios from different payer perspectives. All benefits were discounted at 5% to adjust for their net present value.

RESULTS

Estimates of HVIP cost savings at the base effect estimate of 25% ranged from $82,765 (narrowest model) to $4,055,873 (broadest model).

CONCLUSIONS

HVIPs are likely to produce cost savings. This study provides a systematic framework for the economic evaluation of HVIPs and estimates of HVIP cost savings and cost-benefit ratios that may be useful in informing public policy decisions.