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. 2018 Feb 1;153(2):107-113.
doi: 10.1001/jamasurg.2017.3601.

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

Michael W Wandling  1   2   3 , Avery B Nathens  3   4 , Michael B Shapiro  1 , Elliott R Haut  5   6   7   8
Affiliations

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

Michael W Wandling et al. JAMA Surg. .

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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Conflict of interest statement

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.”

Figures

Figure 1.
Figure 1.. Consort Diagram Illustrating the Selection of Patients From the National Trauma Data Bank Between January 1, 2010, and December 31, 2012
Figure 2.
Figure 2.. Risk-Adjusted Odds Ratios for Mortality for Private Vehicle Transport When Compared With Ground Emergency Medical Services Transport
GSW indicates gunshot wound.
Figure 3.
Figure 3.. Trauma System Subgroup Analyses of Risk-Adjusted Odds Ratios (ORs) for Mortality for Private Vehicle Transport When Compared With Ground Emergency Medical Services Transport
GSW indicates gunshot wound; NA, not applicable. Odds ratios cannot be derived due to small sample size.
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