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

Educational Objective To state the association of mode of transport to the emergency department with mortality in patients with penetrating injuries.
1 Credit CME
Key Points

Question  Does ground emergency medical services transport confer a survival advantage vs private vehicle transport for patients with penetrating injuries?

Findings  In this cohort study of 103 029 patients included in the National Trauma Data Bank, individuals transported by private vehicle were significantly less likely to die than similarly injured patients transported by ground emergency medical services, even when controlling for injury severity.

Meaning  Ground emergency medical services transport is not associated with improved survival compared with private vehicle transport among patients with penetrating injuries in urban trauma systems, suggesting prehospital trauma care may have a limited role in this subset of patients.

Abstract

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.

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Article Information

Corresponding Author: Elliott R. Haut, MD, PhD, Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Sheikh Zayed 6107C, 1800 Orleans St, Baltimore, MD 21287 (ehaut1@jhmi.edu).

Accepted for Publication: June 12, 2017.

Published Online: September 20, 2017. doi:10.1001/jamasurg.2017.3601

Author Contributions: Dr Wandling had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wandling, Nathens, Haut.

Acquisition, analysis, or interpretation of data: Wandling, Shapiro, Haut.

Drafting of the manuscript: Wandling.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Wandling.

Obtained funding: Wandling.

Administrative, technical, or material support: Wandling.

Supervision: Nathens, Shapiro, Haut.

Conflict of Interest Disclosures: Dr Wandling is the primary investigator for training grant F32GM113513 from the National Institute of General Medical Sciences of the National Institutes of Health. Dr Nathens is a paid consultant for the American College of Surgeons Trauma Quality Improvement Program. Dr Haut is primary investigator for research grant 1R01HS024547 from the Agency for Healthcare Research and Quality titled Individualized Performance Feedback on Venous Thromboembolism Prevention Practice. Dr Haut is the primary investigator for 2 contracts from the Patient-Centered Outcomes Research Institute titled Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology (CE-12-11-4489) and Preventing Venous Thromboembolism: Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis (DI-1603-34596). Dr Haut receives royalties from Lippincott, Williams, and Wilkins for Avoiding Common ICU Errors. Dr Haut was the paid author of an article commissioned by the National Academies of Medicine titled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making,” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.”

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