When Equality Is Not Equity: The Ethics of Access to Trauma Care A Surgical Perspective

OBJECTIVE

The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program.

SUMMARY BACKGROUND DATA

Traumatic injury is a leading cause of death and disability in the US. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city leading to a fallacy of distributive justice.

METHODS

A descriptive analysis of community partners, trauma program leadership, trauma surgeons and the violence intervention program director was performed.

RESULTS

The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes (P<0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018 developing both community-based and medical legal partnerships.

CONCLUSIONS

The persistent efforts of the community and key stakeholders led to a system change improving trauma care for the South Side of Chicago.

Influence of Covid-19 Restrictions on Urban Violence

We investigated whether the COVID-19 pandemic affected rates of interpersonal violence (IV). A retrospective study was performed using city-wide crime data and the trauma registry at one high-volume trauma center pre-pandemic [PP] (March-October 2019) and during the pandemic [PA] (March-October 2020). The proportion of trauma admissions attributable to IV remained unchanged from PP to PA, but IV increased as a proportion of overall crime (34% to 41%, p<0.001). Assaults decreased, but there was a proportionate increase in penetrating trauma which was mostly attributable to firearms. Despite a reduction in admissions due to IV in the first 4 months of the pandemic, the rates of violence subsequently exceeded that of the same months in 2019. The cause of the observed increase of IV is multi-factorial. Future studies aimed at identifying the root causes are essential to mitigate violence during this ongoing health crisis.

The American College of Preventive Medicine Policy Recommendations on Reducing and Preventing Firearm-Related Injuries and Deaths

The American College of Preventive Medicine Policy Committee makes policy guidelines and recommendations on preventive medicine and public health topics for public health decision makers. After a review of the current evidence available in 2016, the College is providing a consensus-based set of policy recommendations designed to reduce firearm-related morbidity and mortality in the U.S. These guidelines address seven general areas pertaining to the public health threat posed by firearms: gun sales and background checks, assault weapons and high-capacity weapons, mental health, research funding, gun storage laws, and physician counseling.

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.

Prevalence and risk factors associated with vancomycin-resistant Staphylococcus aureus precursor organism colonization among patients with chronic lower-extremity wounds in Southeastern Michigan

BACKGROUND

Of the 13 US vancomycin-resistant Staphylococcus aureus (VRSA) cases, 8 were identified in southeastern Michigan, primarily in patients with chronic lower-extremity wounds. VRSA infections develop when the vanA gene from vancomycin-resistant enterococcus (VRE) transfers to S. aureus. Inc18-like plasmids in VRE and pSK41-like plasmids in S. aureus appear to be important precursors to this transfer.

OBJECTIVE

Identify the prevalence of VRSA precursor organisms.

DESIGN

Prospective cohort with embedded case-control study.

PARTICIPANTS

Southeastern Michigan adults with chronic lower-extremity wounds.

METHODS

Adults presenting to 3 southeastern Michigan medical centers during the period February 15 through March 4, 2011, with chronic lower-extremity wounds had wound, nares, and perirectal swab specimens cultured for S. aureus and VRE, which were tested for pSK41-like and Inc18-like plasmids by polymerase chain reaction. We interviewed participants and reviewed clinical records. Risk factors for pSK41-positive S. aureus were assessed among all study participants (cohort analysis) and among only S. aureus-colonized participants (case-control analysis).

RESULTS

Of 179 participants with wound cultures, 26% were colonized with methicillin-susceptible S. aureus, 27% were colonized with methicillin-resistant S. aureus, and 4% were colonized with VRE, although only 17% consented to perirectal culture. Six participants (3%) had pSK41-positive S. aureus, and none had Inc18-positive VRE. Having chronic wounds for over 2 years was associated with pSK41-positive S. aureus colonization in both analyses.

CONCLUSIONS

Colonization with VRSA precursor organisms was rare. Having long-standing chronic wounds was a risk factor for pSK41-positive S. aureus colonization. Additional investigation into the prevalence of VRSA precursors among a larger cohort of patients is warranted.