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Original Investigation
September 20, 2017

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

Author Affiliations
  • 1Division of Trauma and Critical Care, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Surgical Outcomes and Quality Improvement Center, Department of Surgery, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 3Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
  • 4Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
  • 5Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
  • 6Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
  • 7Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland
  • 8The Johns Hopkins University School of Public Health, Baltimore, Maryland
JAMA Surg. Published online September 20, 2017. doi:10.1001/jamasurg.2017.3601
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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