Does private vehicle transport in trauma really save you time and money?

Introduction: Current data suggest trauma patients arriving via private vehicle transport (PVT) have improved outcomes compared to patients arriving via EMS due to quicker hospital arrival. Though some researchers have speculated that this may be due to a quicker arrival to the hospital, arrival by PVT may actually impair resuscitation efforts due to the lack of pre-hospital triage leading to delayed mobilization of teams, patient drop-offs at the wrong location, more frequent transfers to another facility, and the transport of patients who may have otherwise been declared dead on scene. This study hypothesizes PVT actually lengthens time to care, impairs resuscitation efforts, and increases overall costs due to the lack of pre-hospital triage. Methods: This is a single-site retrospective study conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. Inclusion criteria were trauma patients presenting to the hospital utilizing PVT that were admitted, died in the emergency department, or transferred out of hospital. Exclusion criteria include patients transferred from outside hospitals. Patients with the same inclusion and exclusion criteria utilizing EMS transportation were the comparison group (N=4997, PVT n=1782). The data were obtained from a trauma registry and chart review. To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data and independent samples t-tests were utilized for continuous data. Results: In total, 36% of trauma patients utilized PVT. Of the 11% of patients were transferred out of the hospital, 60% arrived by PVT. The vast majority (76%) of patients transferred were burn or pediatric patients. The overall rate of DOA was 3%, 89% of which arrived by EMS. There was no significant difference in time from arrival to disposition from the ED overall. However time to disposition was shorter for patients arriving by PVT in patients activated at the highest level and longer for patients who were admitted to the ICU. Cost associated with patients who were transferred out of the hospital and those pronounced DOA are described. Conclusions: Though the hypothesis is supported by the significantly higher proportion of patients who arrived by PVT requiring transfer out of our hospital and associated cost, contrary to the hypothesis there was and no difference with time to disposition overall and a lower proportion of patients who were pronounced DOA. A possible explanation is extensive diagnostic studies and procedures for patients arriving by EMS as previous studies demonstrate these patients are more likely to have poly-trauma, injuries to the head or torso and higher injury severity.https://scholarlycommons.henryford.com/merf2019hvc/1007/thumbnail.jp

Who Skips the Ambulance? A Study Examining Which Patients Choose Private Vehicle Transport Over EMS in Trauma

Introduction: Current data suggest trauma patients arriving via private vehicle transport (PVT) have improved outcomes forpenetrating trauma compared to patients arriving via EMS. These studies suggest patients that utilize EMS overprivate vehicle transport (PVT) have worse outcomes and are described as older, hypotensive, higher injury severityscore (ISS) and lower GCS. While previous studies focus on national data, regional behaviors likely play a role in selection of PVT. This study tests the hypothesis that these findings will also be reflected on a regional level in Detroit. Methods: This study was conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. Inclusion criteria were trauma patients presenting to the hospital utilizing PVT that were admitted, died in the emergencydepartment, or transferred out of hospital. Exclusion criteria includes patients transferred from outside hospitals,burn patients and pediatric patients defined as age less than 15 years old. Patients with the same inclusion and exclusion criteria utilizing EMS were the comparison group (N=4568, PVT n=1498). The data were obtained from a trauma registry and chart review. To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data, and independent samples t-tests were utilized for continuous data. Results: 32.8% of trauma patients arrived via PVT. Of the 16% with penetrating injuries, 39.5% arrived via PVT. Patients arriving via PVT were found to have a significantly higher GCS and lower injury severity, intubation rate, activation level, poly-trauma rate, injury to critical anatomic locations, length of stay, ICU admissions and deaths. Significant differences were also observed with anticoagulation use, self-pay patients, and cognitively impaired patients. Race,age, gender, preexisting comorbidities, intoxication status, vital signs on arrival, and disposition to operating roomor general admission were not different between groups. Conclusions: Findings suggest patients arriving by PVT are in less critical condition with improved outcomes than those arriving by EMS as evidenced by higher GCS, lower intubation rates, lower activation levels, fewer admissions to ICU and lower mortality rates. Though this may suggest a survival benefit, the observation may be because patients arechoosing to call EMS because they recognize a more critical condition. These findings are similar to studies conducted on a national level, however, the rate of utilization of PVT is significantly higher in Detroit suggesting the role of regional factors in PVT utilization.https://scholarlycommons.henryford.com/merf2019clinres/1064/thumbnail.jp

Trauma Patients Still Use Private Vehicle Transport Despite Improvement in EMS Response Times

Introduction: Recently, Detroit has seen a gradual improvement in Emergency Medical Service (EMS) response times. The historically long response times have been implicated in contributing to the high rates of private vehicle transportation (PVT) in Detroit, up to 3 times higher than the national average. This study tests the hypothesis that as EMS arrival times improve, the utilization of PVT in Detroit would decrease. Methods: This is a retrospective study at an academic, regional, Level 1 trauma center in Detroit over 28 months. Inclusion criteria were trauma patients that were admitted, transferred out of hospital, or died. Patients transferred from outside hospitals were excluded (N=2285). The data were obtained from hospital data registry and the city of Detroit’s performance dashboards. Correlation studies were then conducted between average EMS response time and percent PVT utilization and repeated for subgroup analysis by injury severity and trauma cause, and linear regression was conducted if correlation was significant.Results: Though correlation studies show a decline in EMS response time over 28 months with an R2 value of 0.817, there was a weak relationship between PVT usage and time (R2=0.017) and between PVT usage and EMS response time (R2=0.0058). Similar results were seen with subgroup analysis, with the largest R2 value being 0.273 in serious injuries. Conclusions: Despite continued improvement in EMS response times, we did not observe a corresponding decrease in PVT utilization. Potential explanations include a delay in this observation due to a long history of long EMS response time, the general public being unaware of this improvement, or the notion that factors other than historically high EMS arrival times play into this regional phenomenon which we explore through first-responder interviews and patient surveys.https://scholarlycommons.henryford.com/merf2019clinres/1061/thumbnail.jp

The Impact of Age on Outcomes and Mode of Transport in Trauma

Introduction: Current data suggest that trauma patients arriving via private vehicle transport (PVT) have improved outcomes compared to patients arriving via EMS. Additionally, age has been demonstrated to impact patient outcomes in trauma. This study hypothesizes older patients will be more likely to utilize EMS transportation over PVT to the hospital in trauma. Additionally, this study hypothesizes that improved outcomes in PVT will be demonstrated across pediatric, adult, and geriatric age groups. Methods: This study was conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. The data were obtained from a trauma registry and chart review. Inclusion criteria were trauma patients presenting to the hospital utilizing PVT that were admitted, died in the emergency department, or transferred out of hospital. Exclusion criteria included patients transferred from outside hospitals. Patients with the same inclusion and exclusion criteria utilizing EMS were the comparison group (N=4997, PVT n= 1782). Patients were further classified as pediatric (age 0-14, n=276), adults (age 15-64, n=3433), and geriatrics (age \u3e 65, n= 1287). To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data, and independent samples t-tests were utilized for continuous data.Results:In total, 35.7% of trauma patients arrived via PVT. The average age for PVT was significantly lower than EMS (45 and 49, respectively). For all age groups, gender, race and insurance status were not significantly different between groups. All age groups were more likely to be transferred out if they arrived by PVT, average GCS was higher and trauma activation level was lower in PVT across age groups. Mechanism of injury was also significantly different between all age groups.56.9% of pediatric patients sustaining trauma arrived by PVT. These patients were less likely to require operation. Injury Severity Score (ISS), vital signs, anatomic location of injury and outcomes including final disposition, complications and mortality were not significant. 33.9% of adults sustaining trauma arrived by PVT. These patients had lower ISS and were less likely to have injuries to critical locations, require intubation, or require admission to the ICU. They were more likely to be tachycardic, normotensive, sustain poly-trauma, and be placed in observation. Adult patients arriving by PVT had lower LOS, total ICU days, mortality, and complications. They were most likely to be discharged to home. 35.7% of geriatric patients sustaining trauma utilized PVT. Findings were similar to adults, except final disposition showed a greater need for discharge with assistance in the geriatric group. Patients arriving by PVT were more likely to be discharged home with home health and patients by EMS were more likely to require placement in a nursing facility. Outcomes measures are similar to adults with the exception of no significant difference in mortality. Conclusions: The average age of patients arriving by EMS was significantly higher, however, the proportion of patients who arrived by PVT was greatest in pediatric patients. As this hospital is not a pediatric trauma center, prehospital triage may account for the significantly lower use of EMS in this age group. Adults did show lower mortality rates in the PVT group; however, this was not replicated in pediatric or geriatric groups. Excluding pediatric patients, other outcome measures including ICU admissions, ventilator days, length of stay and complications were improved in both geriatric and adult patients utilizing PVT. However, these results were not adjusted for confounding variables. As geriatric patients were more likely to need placement in nursing facilities, this may account for the longer LOS compared to adults.https://scholarlycommons.henryford.com/merf2019clinres/1059/thumbnail.jp

Firearm Injury in Detroit: Examining Seasonal Variability and Outcomes

Background: Firearm injuries contribute substantially each year to premature death, illness, and disability nationally. Previous studies have suggested seasonal variability in total trauma admissions, however there is limited data that specifically examines firearm injury. We hypothesize that when compared to all other trauma, firearm injury demonstrates seasonal variation with increased incidence in summer. Additionally, we anticipate poorer outcomes for firearm injury as measured by length of stay, days in intensive care (ICU), complications, days intubated, mortality, and final disposition. Methods This is retrospective study conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. The data were obtained from a trauma registry and chart review. Inclusion criteria were trauma patients that were admitted, died, or transferred out of the hospital. Patients transferred in were excluded from this study. Patients sustaining a firearm injury were compared to all other traumas admitted in this time period (N=5039, firearm n =580). To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data and independent samples t-tests were utilized for continuous data.ResultsOf the 5039 trauma patients in this period, 580 patients sustained a firearm injury (11.5%). Compared to all other trauma, patients with a firearm injury were more likely to be male, black, intoxicated, uninsured, and younger. On arrival, patients were found to have a significantly lower GCS, higher ISS, lower systolic blood pressure and lower heart rate. Though seasonal variation was observed when examining firearm injury in isolation, there was no significant difference when compared to all other injury (p=0.12). Compared to those with non-firearm injuries, patients who sustained firearm injury are approximately four times as likely to require intubation in the ER or at the scene of injury and were twice as likely to require operation during admission. These patients were also twice as likely to have a complication compared to other trauma patients and twice as likely to have a hospital acquired infection (HAI). Mortality, length of stay, total days in ICU and ventilator-free days were also higher. Patients were less likely to be discharged home without assistance and more likely to be discharged home with home health or to an acute care facility, rehabilitation or jail. Conclusion: Although this study did show seasonal variation in trauma by firearm when examined in isolation, this variation was not significant when compared to all other traumas presenting to the hospital. In other words, trauma admissions are higher overall in warmer months; however, the rise in firearm trauma was proportional to all other trauma. Additionally, firearm injury has significantly worse outcomes in terms of hospital indicators and patient disability when compared to other accidental trauma. This includes significantly higher rates of intubation, mortality, days in ICU, complications including HAIs, and a lower likelihood to be discharged home without assistance. This study may have implications for allocation of resources, injury prevention, and improvement of overall patient care.https://scholarlycommons.henryford.com/merf2019clinres/1058/thumbnail.jp