Distribution of trauma patients evaluated by the Adult Trauma Service, The Johns Hopkins Hospital, Baltimore, Md, from 1955 to 2000. About 80% of the trauma patients reside in the areas shaded in red, orange, and tan. PAL indicates Police Athletic League.
Chang D, Cornwell EE, Phillips J, Baker D, Yonas M, Campbell K. Community Characteristics and Demographic Information as Determinants for a Hospital-Based Injury Prevention Outreach Program. Arch Surg. 2003;138(12):1344-1346. doi:10.1001/archsurg.138.12.1344
Copyright 2003 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2003
To focus the efforts of a hospital-based injury prevention outreach program, information on patient demographics, community characteristics, and catchment area must be known.
Design and Setting
Evaluation of prospectively collected data maintained in the Trauma Registry of a level I university-based trauma center.
Patients and Main Outcome Measures
Demographics, mechanism of injury, mortality, and home ZIP codes of patients admitted to the Adult Trauma Service, The Johns Hopkins Medical Institution, Baltimore, Md, were compared for 2 separate calendar years, at 2 years before (1995) and at 2 years after (2000) the implementation of a dedicated trauma program that includes an injury prevention outreach program.
The list of common patient ZIP codes varied minimally from 1995 to 2000. The 18 most common ZIP codes represent (1) 80% of patients, (2) total area of 99 square miles (257.4 km2) (5.7-mile [9.1-km] radius), and (3) a region with a mean household income that is 67% of the statewide median. An increasingly disproportionate percentage of patients with gunshot wounds (GSWs) were the youngest patients (ages 15-24 years) treated by the Adult Trauma Service. While overall survival of trauma patients improved in 2000, no improvement was seen among patients with GSWs. Over half of the nonsurviving patients (37/65 [57%]) seen in 2000 and more than two thirds of patients with lethal GSWs (25/37 [67.6%]) were declared dead in the emergency department, suggesting nonpreventability from a clinical care standpoint.
The catchment area represented by the bulk of patients admitted to a level I urban trauma center is compact and economically disadvantaged. While overall trauma mortality has decreased, GSWs are more lethal and prevalent in teenagers and young men. This identifies violence prevention as an area of emphasis.
THE AMERICAN College of Surgeons document entitled, "Resources for Optimal Care of the Injured Patient: 1999,"1 stipulates that level I trauma centers are expected to have major activity in prehospital management, education, and injury prevention. Injury prevention activities may take on various forms and include endeavors such as promoting seat belt use for automobile occupants and helmet use for cyclists, as well as promotion of a broad range of violence prevention activities such as youth counseling, after school programs, and structured curricula in conflict resolution. To focus the efforts of a hospital-based injury prevention outreach program, information on patient demographics, community characteristics, and types of injuries seen must be known, so that each trauma center can structure a program that is relevant to its specific clinical experience. The availability of mapping software has made it possible to identify high-volume injury areas that are served by a given trauma center. This article represents an effort by the personnel in a level I trauma center to assess patient demographics and community characteristics to configure an injury prevention outreach program.
Prospectively collected data maintained in the Trauma Registry of a level I university-based trauma center were analyzed. The Trauma Registry is managed by the Collector software (Tri-Analytics, Bel Air, Md) and it collects 90 data elements on each trauma patient, including patient demographics, mechanism of injury, mortality and complications, and hospital charges. Patients' home addresses (not necessarily sites of injury) were entered into Microsoft MapPoint 2001 software (Microsoft Corp, Seattle, Wash) for mapping.
Elements of patient demographics, mechanism of injury, and patient outcomes were analyzed for 2 separate calendar years, at 2 years before (1995) and at 2 years after (2000) the implementation of a dedicated trauma outreach program. The features of the trauma outreach program implemented in 1997-1998 included 24-hour in-house faculty, regular multidisciplinary performance improvement meetings, trauma core curriculum, and an injury prevention outreach program (slide and videotape presentations, hospital visits to see survivors of gun violence) geared toward at-risk youth in the hospital catchment area.
The list of frequently appearing patient home ZIP codes varied minimally from 1995 to 2000. About 80% of the trauma patients reside in 18 ZIP codes (Table 1) that have a total area of 99 square miles (257.4 km2), or approximately a 5.7-mile (9.1-km) radius (Figure 1). The mean household income in this region is 67% of the median for the state, according to the database in Microsoft MapPoint 2001.
Table 2 gives the total number of patients along with sex, mechanism of injury, age breakdown, and mortality. Although the number of patients with gunshot wounds (GSWs) admitted to this level I trauma center dropped dramatically toward the end of the decade, an increasingly disproportionate percentage of patients with GSWs was the youngest patients (ages 15-24 years) treated by the Adult Trauma Service, The Johns Hopkins Medical Institution, Baltimore, Md (62.0% in 2000 vs 53.5% in 1995, P = .03).
Although overall survival of trauma patients improved in 2000, no improvement was seen among patients with GSWs (Table 3). Over half of the nonsurviving patients (37/65 [57%]) seen in 2000 and more than two thirds of the patients with lethal GSWs (25/37 [67.6%]) were declared dead in the emergency department, suggesting nonpreventability from a clinical care standpoint.
Injury prevention activities are becoming an increasingly important component of the activities of a level I trauma center. The pursuit of reducing the effect of injury, once limited to resuscitation and surgical and postoperative clinical management, has advanced to the point where the vast majority of patients arriving alive at trauma centers will ultimately survive.2- 4 Further improvement in mortality must, therefore, include considerations of the particulars of prehospital management and true injury prevention.5,6 Each trauma center is likely to focus its injury prevention activities in a way that is most relevant to its clinical experience.7- 9 It is clear that our trauma center draws the bulk of its patients from a relatively compact and economically disadvantaged area surrounding the hospital. Although patients' addresses are reliably recorded and mapped, we are unable to achieve the same specifics regarding the site of injury because (1) some paramedic run sheets are missing, and (2) patients who get to the hospital without Emergency Medical Services assistance could not provide details on the location of where the injury occurred. However, well-established triage patterns describe a scene-of-injury catchment area for our trauma center that is similar to the area provided by the mapping software used for addresses.
Inspection of Table 2 may raise questions as to why injury prevention activities at our trauma center focuses on prevention of GSWs and intentional injuries in at-risk youths. Why focus on prevention of GSWs when it represents a dramatically decreased proportion of our clinical activity (12.7% in 2000 vs 26.3% in 1995, P<.01)? The answer is found in both the demographic information and the mortality data. Although penetrating trauma represented a less common mechanism of injury in the year 2000, patients in the earliest decade of life (ages 15-24 years) treated by the Adult Trauma Service represented a dramatically greater proportion of all GSWs. While this age group represented 33% of the total number of patients admitted to the Adult Trauma Service, they represented almost two thirds of the patients admitted with GSWs. More importantly, as the implementation of the dedicated trauma program was associated with a significant decrease in overall mortality (Table 3), no progress was made in saving patients presenting with GSWs.
The importance of true injury prevention is highlighted when one looks at Table 3. Almost 99% of patients leaving the emergency department alive in 2000 ultimately survived, a significant improvement over 1995. While the numbers were not large enough for trends in mortality reduction among the more severely injured subset (Injury Severity Score >15, or severe head injury) to achieve statistical significance, there was not even a suggestion of improvement in mortality among patients with GSWs because two thirds of those who died were either dead on arrival or declared dead shortly thereafter. Therefore, we have established a multidisciplinary community outreach collaborative targeting youth residing in the area responsible for the greatest number of trauma patients with GSWs. We have developed a relationship with the Police Athletic League Center located in the high-volume region (Figure 1, outreach site). Specific interventions include dissemination of videotapes aimed at adolescents dramatizing the true consequences of gun violence, slide presentations by health care professionals graphically depicting the anatomical damage produced by gun violence, hospital tours to visit survivors of interpersonal violence, and inpatient counseling and outpatient referral and follow-up for young trauma patients whose injuries were alcohol and/or drug related.
Since most patients with lethal GSWs are declared dead shortly after arrival in the emergency department and these injuries disproportionately affect the youngest segment of the population, and most importantly, since the mortality of GSWs did not improve despite a broad-reaching institutional commitment to overall trauma care, we have identified violence prevention among at-risk youth as a major area of emphasis in our hospital-based injury prevention outreach program.
Corresponding author and reprints: Edward E. Cornwell III, MD, The Johns Hopkins Hospital, 600 N Wolfe St, Osler 625, Baltimore, MD 21287 (e-mail: firstname.lastname@example.org).
Accepted for publication May 26, 2003.
This study was supported in part by the American Trauma Society, Arlington, Va.
This study was presented at the 73rd Pacific Coast Surgical Association Meeting; February 17, 2002; Las Vegas, Nev; and is published after peer review and revision.