Injury-adjusted mortality of patients transported by police following penetrating trauma

Outcomes of Trauma "Walk-Ins" in the American College of Surgeons Trauma Quality Program Database

BACKGROUND

Outcomes of trauma "walk-in" patients (using private vehicles or on foot) are understudied. We compared outcomes of ground ambulance vs walk-ins, hypothesizing that delayed resuscitation and uncoordinated care may worsen walk-in outcomes.

METHODS

A retrospective analysis 2020 American College of Surgeons Trauma Quality Programs (ACS-TQP) databases compared outcomes between ambulance vs "walk-ins." The primary outcome was in-hospital mortality, excluding external facility transfers and air transports. Data was analyzed with descriptive statistics, bivariate, multivariable logistic regression, including an Inverse Probability Weighted Regression Adjustment with adjustments for injury severity and vital signs. The primary outcome for the 2019 (pre-COVID-19 pandemic) data was similarly analyzed.

RESULTS

In 2020, 707,899 patients were analyzed, 556,361 (78.59%) used ambulance, and 151,538 (21.41%) were walk-ins. We observed differences in demographics, hospital attributes, medical comorbidities, and injury mechanism. Ambulance patients had more chronic conditions and severe injuries. Walk-ins had lower in-hospital mortality (850 (.56%) vs 23,131 (4.16%)) and arrived with better vital signs. Multivariable logistic regression models (inverse probability weighting for regression adjustment), adjusting for injury severity, demographics, injury mechanism, and vital signs, confirmed that walk-in status had lower odds of mortality. For the 2019 (pre-COVID-19 pandemic) database, walk-ins also had lower in-hospital mortality.

DISCUSSION

Our results demonstrate better survival rates for walk-ins before and during COVID-19 pandemic. Despite limitations of patient selection bias, this study highlights the need for further research into transportation modes, geographic and socioeconomic factors affecting patient transport, and tailoring management strategies based on their mode of arrival.

Prehospital Trauma Care

Prehospital trauma evaluation begins with the primary assessment of airway, breathing, circulation, disability, and exposure. This is closely followed by vital signs and a secondary assessment. Key prehospital interventions include management and resuscitation according to the aforementioned principles with a focus on major hemorrhage control, airway compromise, and invasive management of tension pneumothorax. Determining the appropriate time and method for transportation (eg, ground ambulance, helicopter, police, private vehicle) to the hospital or when to terminate resuscitation are also important decisions to be made by emergency medical services clinicians.

Prehospital transportation of severe penetrating trauma victims in Sweden during the past decade: a police business?

INTRODUCTION

Sweden is facing a surge of gun violence that mandates optimized prehospital transport approaches, and a survey of current practice is fundamental for such optimization. Management of severe, penetrating trauma is time sensitive, and there may be a survival benefit in limiting prehospital interventions. An important aspect is unregulated transportation by police or private vehicles to the hospital, which may decrease time but may also be associated with adverse outcomes. It is not known whether transport of patients with penetrating trauma occurs outside the emergency medical services (EMS) in Sweden and whether it affects outcome.

METHOD

This was a retrospective, descriptive nationwide study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 registered in the Swedish national trauma registry (SweTrau) between June 13, 2011, and December 31, 2019. We hypothesized that transport by police and private vehicles occurred and that it affected mortality.

RESULT

A total of 657 patients were included. EMS transported 612 patients (93.2%), police 10 patients (1.5%), and private vehicles 27 patients (4.1%). Gunshot wounds (GSWs) were more common in police transport, 80% (n = 8), compared with private vehicles, 59% (n = 16), and EMS, 32% (n = 198). The Glasgow coma scale score (GCS) in the emergency department (ED) was lower for patients transported by police, 11.5 (interquartile range [IQR] 3, 15), in relation to EMS, 15 (IQR 14, 15) and private vehicles 15 (IQR 12.5, 15). The 30-day mortality for EMS was 30% (n = 184), 50% (n = 5) for police transport, and 22% (n = 6) for private vehicles. Transport by private vehicle, odds ratio (OR) 0.65, (confidence interval [CI] 0.24, 1.55, p = 0.4) and police OR 2.28 (CI 0.63, 8.3, p = 0.2) were not associated with increased mortality in relation to EMS.

CONCLUSION

Non-EMS transports did occur, however with a low incidence and did not affect mortality. GSWs were more common in police transport, and victims had lower GCS scorescores when arriving at the ED, which warrants further investigations of the operational management of shooting victims in Sweden.

Improvement in trauma care for road traffic injuries: an assessment of the effect on mortality in low-income and middle-income countries

Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

Association between Mode of Transportation and Survival in Adult Trauma Patients with Penetrating Injuries: Matched Cohort Study between Police and Ground Ambulance Transport

INTRODUCTION

Police transport (PT) of penetrating trauma patients has the potential to improve survival rates. There are no well-established guidelines for PT of penetrating trauma patients.

STUDY OBJECTIVE

This study examines the association between survival rate to hospital discharge of adult penetrating trauma patients and mode of transport (PT versus ground ambulance [GA]).

METHODS

A retrospective, matched cohort study was conducted using the United States (US) National Trauma Data Bank (NTDB). All adult penetrating injury patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by GA for analysis. Descriptive analysis was carried out. The patients' demographic and clinical characteristics were tabulated and stratified by the transport mode.

RESULTS

Out of the 733 patients with penetrating injuries, ground Emergency Medical Services (EMS) transported 513 patients and police transported 220 patients. Most patients were 16-64 years of age with a male (95.6%) and Black/African American race (79.0%) predominance. Firearm-related injuries (68.8%) were the most common mechanism of injury with the majority of injuries involving the body extremities (62.9%). Open wounds were the most common nature of injury (75.7%). The overall survival rate to hospital discharge was similar for patients transported by GA and by police (94.5% versus 92.7%; P = .343).

CONCLUSION

In this study, patients with penetrating trauma transported by police had similar outcomes to those transported by GA. As such, PT in penetrating trauma appears to be effective. Detailed protocols should be developed to further improve resource utilization and outcomes.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Police transport of firearm-injured patients-more often and more injured

BACKGROUND

Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured.

METHODS

We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression.

RESULTS

Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients.

CONCLUSION

Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients.

LEVEL OF EVIDENCE

Epidemiological, level III.

Association between Mode of Transportation and Survival in Adult Trauma Patients with Blunt Injuries: Matched Cohort Study between Police and Ground Ambulance Transport

INTRODUCTION

Early police transport (PT) of penetrating trauma patients has the potential to improve survival rates for trauma patients. There are no well-established guidelines for the transport of blunt trauma patients by PT currently.

STUDY OBJECTIVE

This study examines the association between the survival rate of blunt trauma patients and the transport modality (police versus ground ambulance).

METHODS

A retrospective, matched cohort study was conducted using the National Trauma Data Bank (NTDB). All blunt trauma patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by ground Emergency Medical Services (EMS) for analysis. Descriptive analysis was carried out. This was followed by comparing all patients' characteristics and their survival rates in terms of the mode of transportation.

RESULTS

Out of the 2,469 patients with blunt injuries, EMS transported 1,846 patients and police transported 623 patients. Most patients were 16-64 years of age (86.2%) with a male predominance (82.5%). Fall (38.4%) was the most common mechanism of injury with majority of injuries involving the head and neck body part (64.8%). Fractures were the most common nature of injury (62.1%). The overall survival rate of adult blunt trauma patients was similar for both methods of transportation (99.2%; P = 1.000).

CONCLUSION

In this study, adult blunt trauma patients transported by police had similar outcomes to those transported by EMS. As such, PT in trauma should be encouraged and protocolized to improve resource utilization and outcomes further.

Advancing Prehospital Combat Casualty Evacuation: Patients Amenable to Aeromedical Evacuation via Unmanned Aerial Vehicles

INTRODUCTION

The U.S. military currently utilizes unmanned aerial vehicles (UAVs) for reconnaissance and attack missions; however, as combat environment technology advances, there is the increasing likelihood of UAV utilization in prehospital aeromedical evacuation. Although some combat casualties require life-saving interventions (LSIs) during medical evacuation, many do not. Our objective was to describe patients transported from the point of injury to the first level of care and characterize differences between patients who received LSIs en route and those who did not.

MATERIALS AND METHODS

We conducted a retrospective review of the records of traumatically injured patients evacuated between January 2011 and March 2014. We compared patient characteristics, complications, and outcomes based on whether they had an LSI performed en route (LSI vs. No LSI). We also constructed logistic regression models to determine which characteristics predict uneventful flights (no en route LSI or complications).

RESULTS

We examined 1,267 patient records; 47% received an LSI en route. Most patients (72%) sustained a blast injury and injuries to the extremities and head. Over 78% experienced complications en route; the LSI group had higher rates of complications compared to the No LSI group. Logistic regression showed that having a blunt injury or the highest abbreviated injury scale (AIS) severity score in the head/neck region are significant predictors of having an uneventful flight.

CONCLUSION

Approximately half of casualties evaluated in our study did not receive an LSI during transport and may have been transported safely by UAV. Having a blunt injury or the highest AIS severity score in the head/neck region significantly predicted an uneventful flight.

Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma

Background

Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders.

Methods

This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice.

Results

Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow.

Conclusions

Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency.

Level of evidence

Epidemiological study, level III.

Factors Associated with Survival in Adult Trauma Patients Transported to US Trauma Centers by Police

INTRODUCTION

Police units often reach the trauma scene before Emergency Medical Services (EMS). Initiatives aiming at delivering early basic trauma care by non-medical providers including police personnel are on the rise. This study describes characteristics of trauma patients transported by police to US hospitals and identifies factors associated with survival in this patient population.

METHODS

Using the 2015 National Trauma Data Bank (NTDB), an observational study was conducted of adult trauma patients who were transported by police. After describing the study population, the factors associated with survival to hospital discharge were evaluated using a multivariate analysis.

RESULTS

A total of 2,394 patients were included in the study. Patients had a median age of 34.0 years (interquartile range [IQR]: 25-48) and most were males (84.5%). Blunt trauma mechanism (59.4%) was more common than penetrating trauma (29.4%). Factors associated with improved survival included: comorbidity (odds ratio [OR] = 2.92; 95% CI, 1.33-6.40); use of drugs (OR = 2.91; 95% CI, 1.07-7.92); cut/pierce (OR = 11.07; 95% CI, 2.10-58.43); motor vehicle traffic (MVT) mechanism (OR = 6.56; 95% CI, 1.60-26.98); trauma resulting in fractures (OR = 3.03; 95% CI, 1.38-6.64); and private/commercial insurance (OR = 3.41; 95% CI, 1.10-10.55).

CONCLUSION

In this study population, a relatively high survival rate was noted (93.5%). Police transport of patients with blunt trauma was unexpectedly more common. Factors associated with survival to hospital discharge were identified. These factors can be used to implement more standardized and protocol-driven risk stratification tools of trauma patients on scene to improve police involvement in trauma patient transport.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®

PURPOSE

The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients.

METHODS

In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room.

RESULTS

We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention.

CONCLUSION

Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds

BACKGROUND

Shorter prehospital time in patients sustaining penetrating trauma has been shown to be associated with improved survival. Literature has also demonstrated that police transport (vs. Emergency Medical Services [EMS]) shortens transport times to a trauma center. The purpose of this study was to determine if ShotSpotter, which triangulates the location of gunshots and alerts police, expedited dispatch and transport of injured victims to the trauma center.

METHODS

All shootings which occurred in Camden, NJ, from 2010 to 2018 were reviewed. Demographic, geographic, response time, transport time, and field intervention data were collected from medical and police records. We compared shootings where the ShotSpotter was activated versus shootings where ShotSpotter was not activated. Incidents, which did not occur in Camden or where complete data were not available, were excluded as were patients not transported by police or EMS.

RESULTS

There were 627 shootings during the study period which met inclusion criteria with 190 (30%) activating the ShotSpotter system. Victims involved in shootings with ShotSpotter activation were more severely injured, more likely to be transported by police, less likely to undergo trauma bay resuscitative measures, and more likely to receive blood products. Mortality, when adjusted for distance, Trauma, and Injury Severity Score, Injury Severity Score, and shock index, was not significantly different between ShotSpotter and non-ShotSpotter incidents. ShotSpotter activation significantly reduced both the response time as well as transport time for both police and EMS (all p < 0.05).

CONCLUSION

The activation of the ShotSpotter technology increased the likelihood of police transport of gunshot victims. Furthermore, the use of this technology resulted in shorter response times as well as transport times for both police and EMS. This technology may be beneficial in enhancing the care of victims of penetrating trauma.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services

Importance

Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes.

Objective

To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems.

Design, Setting, and Participants

Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle.

Main Outcome and Measure

In-hospital mortality.

Results

Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR,  0.45; 95% CI, 0.36-0.56) and stab wound (OR,  0.32; 95% CI, 0.20-0.52) subgroups.

Conclusions and Relevance

Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Use of Emergency Medical Services by Police

OBJECTIVES

Many police officers receive medical training for limited assessments and interventions. In most situations where medical issues arise, however, emergency medical services (EMS) are called for evaluation, treatment, and transport. Given the limited amount of information about such encounters we examined officer calls for EMS help in a single system to better describe these encounters.

METHODS

Requests for medical help from a fire-based EMS system by police in a moderate-sized city in 2014 and 2015 were identified. In this system, fire department resources are requested for initial evaluations of any medical complaint. Data were extracted from fire records including disposition, transportation from scene, type of injury or illness, and vital signs. Data analysis used descriptive statistics.

RESULTS

4,792 calls were made, representing 2.2% of all police-citizen interactions and 4.2% of all EMS calls. A total of 61.2% of calls resulted in transport to hospital. Of those, 5.6% required fire-based advanced life support; the remainder were transported by private basic life support ambulance or non-medical means. Most requests were for trauma (51.4%), followed by medical (24.7%), drug/alcohol use (17.1%), and psychiatric (6.7%). Vital signs tended to be within normal limits including 72.7% of pulses, 65.1% of systolic blood pressures, and 90.5% of respiratory rates.

CONCLUSION

Requests for EMS assistance from police were common. Most calls involved patients with normal vital signs who did not require advanced life support transport. Further research is needed to identify situations where increased officer training and change in protocols could potentially change EMS response models and improve efficiency of the system.

The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma

BACKGROUND

The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.

OBJECTIVE

We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.

METHODS

We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.

RESULTS

There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).

CONCLUSIONS

We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

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.

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes

BACKGROUND

Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport.

METHODS

Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived.

RESULTS

Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50).

CONCLUSIONS

Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment

BACKGROUND

Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers.

METHODS

A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression.

RESULTS

During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7).

CONCLUSION

Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport

BACKGROUND

Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV).

STUDY DESIGN

We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility.

RESULTS

74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35).

CONCLUSIONS

Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Severity-adjusted mortality in trauma patients transported by police

STUDY OBJECTIVE

Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia.

METHODS

This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index.

RESULTS

Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police.

CONCLUSION

We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care.

IV access in bleeding trauma patients: a performance review

BACKGROUND

Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay.

METHODS

We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion.

RESULTS

Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12).

CONCLUSIONS

We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge.