Description:

Presenter: Mike Wandling, MD

Introduction:
The role of pre-hospital trauma care of injured patients remains a topic of considerable debate. Previous studies have evaluated the impact of mode of transport, transport times, and the intensity of pre-hospital procedures on morbidity and mortality following trauma. However, these studies are primarily from either a single center or the entire country, including all geographic regions (urban, suburban, rural) equally. These previous results are inconsistent and local pre-hospital systems continue to have varying protocols. We aimed to identify the optimal mode of transport for individuals suffering penetrating injury within urban trauma systems.

Methods:
Using the American College of Surgeons National Trauma Databank (NTDB), we identified all adult (age  16) gunshot wound and stab wound patients presenting to level 1 and level 2 trauma centers from 2010 to 2012. Cases were limited to those occurring in the 100 most populous US metropolitan areas using unblinded facility identification and hospital zip code information. Patients were included if they were transported directly to the trauma center by ground emergency medical services (EMS), police, or private transportation and had complete records with regard to the primary outcome of mortality. Mortality rates for pre-hospital mode of transport were calculated and the odds ratio of risk-adjusted mortality for each transport mode were derived.

Results:
Of 108,582 patients, 88,826 (81.8%) were EMS, 17,284 (15.9%) were private, and 2,472 (2.3%) were police. The overall mortality rate was 10.2%. After adjusting for age, gender, race, injury severity, presenting systolic blood pressure, presenting heart rate, Glasgow Coma Scale Motor score, year of admission, and insurance status, private vehicle patients were significantly less likely to die when compared to EMS patients (OR=0.48, 95% CI: 0.40-0.58). There was no mortality difference between EMS and police transported patients (OR=0.94, 95% CI: 0.66-1.34).

Conclusion:
By using facility identifier and hospital zip code data in the NTDB, we demonstrate that in urban settings, private transport is associated with higher survival compared to EMS transport for victims of penetrating trauma. Although similar findings have been previously reported, this is the first time the data have been restricted to the urban setting. By limiting these analyses to large metropolitan areas, the results can stimulate the evaluation and optimization of pre-hospital care within urban trauma systems nationwide.