15.09 Blunt Cerebrovascular Injury: Does Early Therapy Alter Injury Grade?

Posted on January 18, 2018

A. Kaple2, I. Catanescu1, M. C. Spalding1  1Grant Medical Center,Trauma,Columbus, OHIO, USA 2Ohio University,Heritage College Of Osteopathic Medicine,Dublin, OHIO, USA

Introduction:  Blunt cerebrovascular injury (BCVI) affects 1-2% of all traumas and leads to increased risk of stroke and neurological sequelae if not treated. However, many cases of BCVIs occur in a poly-trauma setting, delaying the initiation of antiplatelet therapies (APT). Such cases include comorbidities like solid organ injury and traumatic brain injury. Though studies have suggested that it is safe to start APT in certain cases, there is a lack of data in regards to timing of therapy initiation. The purpose of our study was to analyze the change in grade of BCVI as a function of initiation of APT.
 

Methods:  This was a retrospective study of blunt traumas with radiographic BCVI diagnosis performed at a level one trauma center from October 2016 to July 2017. Initially, the cohort included 115 patients. Exclusion criteria was defined as; injuries by a penetrating mechanism, atherosclerotic vessels, or confounding artifact on imaging. 104 blunt trauma patients with 153 total blood vessel injuries comprised the study population. Variables analyzed included; neurological exam, medication used for APT, time to initiate treatment, and angiographic findings. Primary outcomes were; death, stroke, resolution or progression of BCVI. Secondary outcomes included; hospital and ICU stay, DVT, sepsis, and cardiac arrest. We defined early treatment as an initiation under 48 hours, between 2-10 days, and greater than 10 days. Patients were organized by Grade of BCVI, and then compared between different treatment initiation times.
 

Results: Out of 153 BCVIs, 58.2% were Grade 1, 17.6% were Grade 2, 15.7% were Grade 3, 8.5% were Grade 4, and no Grade 5 injuries were encountered. There was a significantly higher mortality for patients with a Grade 4 BCVI (p < 0.05). Regarding the outcomes of Grade 1 BCVIs, there were significant differences when compared to other grades (p < 0.05).  However, there was no statistical significance in the timing of treatment versus BCVI progression (p=0.73). For BCVIs treated under 48 hours, 59.6% improved.  When treated between 2 and 10 days, 56.3% of BCVIs improved. BCVIs treated after 10 days had an improvement rate of 66.7%. Treatment arms were no different between those injuries that remained the same and those that were not treated (Table 1). 
 

Conclusion: Our study found that Grade 4 BCVI mortality was statistically significant, as well as Grade 1 BCVIs and outcomes. However, when we analyzed BCVI progression, we found that there was no statistical significance between progression and early treatment time. It appears that early treatment may not need to be initiated promptly; however, we acknowledge a limitation is that this calculation is underpowered.  Future research will continue to compile BCVI data to enhance our sample size so that a potentially efficacious time period is found to initiate APT.    

 

15.04 The Positive Impact of Methadone Treatment on Trauma Patient Outcomes

Posted on January 18, 2018

S. M. Miller1, S. N. Lueckel1, D. S. Hefferenan1, A. H. Stephen1, M. D. Connolly1, T. Kheirbek1, W. G. Cioffi1, C. A. Adams1, S. F. Monaghan1  1Brown University School Of Medicine,Surgery,Providence, RI, USA

Introduction:  Each day 78 people die from opioid-related overdoses in the United States. With heightened public awareness, the number of people in methadone treatment programs has increased. Methadone treatment was not intended to be a chronic medication and we predict methadone treatment will be associated with adverse outcomes in trauma patients. 

Methods:  The trauma registry of a single level-one trauma center was queried between 2011 and 2016 for patients who were tested for drug use and were grouped based on their methadone use. First demographic and outcome measures were compared among all patients. Then, case-control matching (2 controls for every case) was then performed for between groups, matching for age, gender, Glasgow coma scale (GCS), and injury severity score (ISS). Regression analysis was used to identify variables affecting patient outcomes. Alpha was set to 0.05. 

Results:6848 patients tested for drugs on admission were identified from the trauma registry; 175 were in the methadone group and 6673 were controls. Patients on methadone were younger (43 years vs 52, p<.001) but had similar gender, racial and ethnicity group distributions. There was no significant difference in mechanism of injury, ISS, or GCS on admission. Methadone patients were more likely to have a psychiatric illness (29% vs 17%, p<.001), to smoke (62% vs 31, p<.001) and to use illegal drugs (90% vs 63%, p<.001), while they were less likely to have hypertension (15% vs 32%, p<.001), diabetes (6% vs 11%, p<.05), and congestive heart failure (2% vs 5%, p<.05). The hospital mortality was lower in the methadone group (3% vs 6%, p<.05). Case-control matching yielded a cohort of 509 patients, 170 of whom were on methadone. In the matched sample (with similar age, gender, GCS and ISS), methadone patients were more likely to have a psychiatric illness (30% vs 7%, p<.001), to smoke (62% vs 45%, p<.001) and to use illegal drugs (89% vs 68%, p<.001). Similarly, methadone patients demonstrated lower mortality (2% vs 17%, p<.001) but were observed to have longer lengths of stay in the hospital (9 days vs 7, p<.05). In addition, patients receiving methadone treatment were less likely to be discharged home with no services (51% vs 82%, p<.001). Regression analyses revealed that methadone patients had lower mortality (OR = 21, 95% CI 5.5-79, p<.001) when adjusting for patient and injury characteristics. 

Conclusion: Counter to our hypothesis, patients on methadone were more likely to survive than those not taking methadone. Chronic narcotics may have a salutary effect on injured-induced immune-inflammatory activation. However, patients on methadone were hospitalized for two days longer. This potentially speaks to difficulty in placing patients with services due to the methadone use. 

 

15.07 National Trends in Use and Outcomes of Nonoperative Management versus Splenectomy at Trauma Hospitals

Posted on January 18, 2018

T. Bongiovanni1, A. Stey1, A. Conroy1, C. Wybourn1, R. A. Callcut1  1University Of California – San Francisco,Zuckerberg San Francisco General Hospital, Department Of Surgery, General And Trauma Surgery,San Francisco, CA, USA

Introduction: In 2003, national guidelines were first published recommending potential benefit to non-operative management for hemodynamically stable patients suffering splenic injury.  In 2012, updated guidelines supported extension of non-operative therapy to higher-grade injuries and older patients in the presence of hemodynamic stability.  This study investigates the adoption of non-operative therapy by examining national trends and associated outcomes.

Methods:  The National Trauma Data Bank National Sample Program weighted file was used to conduct an observational and serial cross-sectional cohort study between January 1, 2008 and December 31, 2012, identifying hospitalizations during which a patient greater than 12 years old was diagnosed with a traumatic splenic injury. 

Results: Among the almost 3.5 million unique patients in the database, there were 47,212 splenic injuries documented from the years 2008-2012 (69% men, mean [SD] 37.8 [18.1] years) for traumatic splenic injury, of which 9,961 (21%) underwent operative intervention.

Interestingly, there was as overall decrease in reporting of splenic injuries by 2011 and 2012, though there was no change in OR use (210 per 1000 injuries in 2008 vs 220 per 1000 injuries in 2012).  Over the 5 year study period, there was no improvement in the mean length of stay (11.5 days in 2008, 11.0 days in 2012) or in the number of ICU days (4.81 days in 2008, 5.13 days in 2012). However, the rates of transfusion have increased dramatically from 2008 to 2012 (FFP transfusion 3.0% to 8.2%, p<0.001, platelet transfusion 1.4% to 4.8%, p<0.001, pRBC 9.3% to 18.7%, p<0.001). 

In multivariate regression, controlling for age, injury severity score, GCS upon arrival, transfusions of FFP, platelets, prbcs, race, and tachycardia or hypotension in the emergency department, there was no significant difference in survival among each year of analysis. 

Conclusion: Within 5 years of the initial recommendations for non-operative therapy, the rate of surgical intervention had plateaued and remained stable in the subsequent years 2008-2012.  However, the rate of transfusion has continued to climb suggesting that patient exposure to blood products has increased while attempting splenic preservation.  Further investigation should be done to better elucidate the reasons for increased transfusions requirement, and possible delayed care in these patients. 
 

15.08 Outcomes After TBI in Patients on P2Y12 Inhibitors: Is There a Need for Platelet Transfusion?

Posted on January 18, 2018

F. S. Jehan1, M. Zeeshan1, A. Jain1, T. O’Keeffe1, N. Kulvatunyou1, A. Tang1, L. Gries1, E. Zakaria1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The role of the cyclooxygenase inhibitor (Aspirin) is well studied; however, the reversal of P2Y12 inhibitors after intracranial hemorrhage remains unclear. The aim of our study is to evaluate outcomes after traumatic brain injury in patients who are on preinjury P2Y12 inhibitors.

Methods:
We analyzed our prospectively maintained traumatic brain injury database from 2014-2106 and included all patients with intracranial hemorrhage (ICH) who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for the age, gender, race, admission Glasgow coma scale (GCS) score, transfusion of blood products, severity of injury, type and size of ICH. Outcome measures included progression of ICH, adverse discharge disposition (SNiF), and mortality.

Results:
A total 243 patients with ICH were on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 + 18 years, 58% were males and 60% were white while the median [IQR] ISS was 14[9-22]. 74% received platelet transfusion after admission. The mean units of platelet transfusion were 1.6 + 2 units. On regression analysis after controlling for confounders, patients who received platelet transfusion had lower rate of progression of ICH on repeat head CT scan (OR: 0.77; 95%CI [0.4-0.8], p=0.01), and decreased rate of neurosurgical intervention (OR: 0.86; 95%CI [0.32-0.9], p=0.03) compared to those who did not. Overall mortality was 11%. In addition, patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility SNiF (OR: 0.71; 95%CI [0.5-0.0.8], p=0.02) and mortality (OR: 0.85; 95%CI [0.44-0.91], p=0.02) as well compared to those patients who did not receive platelet transfusion. 

Conclusion:
Platelet transfusion after traumatic ICH in patients on P2Y12 inhibitors is associated with decreased risk of progression and neurosurgical intervention after traumatic intracranial hemorrhage. In addition, patients with platelet transfusion had lower mortality and were less likely to be discharged to a SNiF. Further randomized studies are required to unify the practice of platelet transfusion after ICH in patients on P2Y12 inhibitors to improve outcomes.
 

15.02 Obese Patients Have a Higher Need for Dialysis After Trauma

Posted on January 18, 2018

A. Grigorian1, N. T. Nguyen1, B. Smith1, B. J. Williams1, S. Schubl1, V. Joe1, D. Elfenbein1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction: Obesity is a well-known risk factor for diabetes and hypertension which are the leading causes of end-stage renal disease (ESRD). Obesity is also a risk factor for the development of acute kidney injury (AKI). The effect of obesity on the need for dialysis in trauma has not been elucidated. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis after trauma.

Methods: This was a retrospective analysis using the National Trauma Data Bank. We included all patients 18 years of age and older. Patients were grouped based on their BMI: normal (18.5-24.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2) and morbidly obese (> 40 kg/m2). The primary outcome was the need for dialysis. Patients with chronic renal failure were excluded from the analysis since a high proportion of these patients may have been on dialysis prior to their admission. We performed a multivariate linear regression analysis after controlling for significant cofactors.

Results: There were 1,221,990 patients included in the study. The obese group differed from the normal BMI group by age (median, 52.0 vs 38.0), history of diabetes (17.7% vs 6.8%), amount of traumatic brain injury (27.6% vs 30.5%) and lower extremity injury (26.2% vs 23.8%) but no difference in injury severity score (p>0.05). The severely obese group were older (median, 53.0 vs 38.0), had more ESRD (1.5% vs 1.1%) and hypertension (41.6% vs 24.6%). Morbidly obese patients were older (median, 50.0 vs 38.0) and had more lower extremity injuries (30.6% vs 23.8%). There was no difference among groups in regards to ICU stay and ventilatory days (p>0.05). Morbidly obese patients had a higher incidence of rhabdomyolysis (0.1% vs 0.02%), AKI (1.1% vs 0.4%) and mortality (3.1% vs 2.8%). After adjusting for covariates, we found that BMI > 30 kg/m2 (Odds ratio [OR]=1.21, confidence intervals [CI] 1.10-1.33, p<0.001), BMI > 35 kg/m2 (OR=1.50, CI=1.34-1.80, p<0.001) and > 40 kg/m2 (OR=1.84, CI=1.64-2.06, p<0.001) had a stepwise increased need for dialysis after trauma.

Conclusion: Trauma patients with a BMI > 30 kg/m2 are associated with increased risk for dialysis in a large database. This holds true even after controlling for multiple well-known risk factors for acute renal failure in trauma patients. Aggressive screening and treatment of obese trauma patients may help prevent acute renal failure requiring dialysis.

 

15.03 Supratherapeutic INR in the Elderly Trauma Patient: Is It Lethal?

Posted on January 18, 2018

D. Sharma1, L. Sadri1, A. Rogers1, G. Filosa1, Q. Yan1, R. Shadis1, R. Josloff1, T. Vu1  1Abington Memorial Hospital,Abington, PA, USA

Introduction:  Elderly patients (>65 years) often present to the trauma bay on anticoagulants with an elevated INR. Among these patients, traumatic brain injury (TBI) is a common mechanism of injury. We aim to investigate if elderly patients presenting with supratherapeutic INRs have increased mortality compared to those with therapeutic and subtherapeutic INRs after blunt trauma. For patients with TBI, we will also determine if a supratherapeutic INR has higher risk of mortality.

Methods:  A retrospective chart review was performed for patients on the trauma service from 2010 to 2015 at Abington Jefferson Hospital, a level 2 trauma center. Elderly patients on anticoagulation with blunt traumatic injury were divided into three cohorts based on INR: subtherapeutic (< 2.0), therapeutic (2.0-3.5), and supratherapeutic INR (>3.5). The primary outcome of mortality and relative risk (RR) was determined for each group, with the therapeutic group serving as the control. The data was then stratified by mechanism of injury (TBI versus other polytrauma) and mortality and relative risk was reported by INR cohorts.

Results: 

Seven hundred and forty-seven patients were included. In this group, 189 patients were subtherapeutic (25%), 440 were therapeutic (59%), and 118 were supratherapeutic (16%). There was no statistically significant difference in mortality rates between the subtherapeutic group and therapeutic group (RR: 0.58; 95% CI: 0.24-1.40; P = 0.23). However, compared to the therapeutic group, the supratherapeutic group had a statistically significant increase in mortality (RR: 2.18; 95% CI: 1.16-4.07; P= 0.015).  

Of the 220 patients with TBI, the mortality of the subtherapeutic (N = 53), therapeutic (N = 123) and supratherapeutic group (N = 26) was 1.9%, 12.2% and 46.2%, respectively. The RR of death of the subtherapeutic group compared to therapeutic group was 0.15 and not statistically significant (95% CI: 0.02-1.14; P = 0.067). However, compared to the therapeutic group, the supratherapeutic group had a significantly higher risk of mortality (RR: 3.78; 95% CI: 2.02-7.11; P < 0.0001).  

Of 545 patients without TBI, the mortality of the subtherapeutic (N = 136), therapeutic (N = 317) and supratherapeutic groups (N = 92) were 3.7%, 2.8% and 2.2%, respectively. Compared to the therapeutic group, the RR of death was not statistically significant for the subtherapeutic (p=0.64) or supratherapeutic group (P = 0.73).

 

Conclusion: Elderly trauma patients with supratherapeutic INRs have a significantly higher risk of death during hospitalization than those with therapeutic or subtherapeutic INRs. Furthermore, those with traumatic brain injury and supratherapeutic INRs also have a significantly higher risk of death. Therefore, elderly patients on anticoagulants with supratherapeutic INRs warrant purposeful and aggressive monitoring given the increased risk of mortality following blunt traumatic injury.
 

14.15 Risk factors and economic implications of opioid poisoning in trauma

Posted on January 18, 2018

W. C. Kethman1, L. Sceats1, L. Tennakoon1, K. L. Staudenmayer1  1Stanford University,Division Of Trauma And Critical Care,Palo Alto, CA, USA

Introduction:  The CDC reported that 11.5M non-institutionalized adults misused opioids in 2015. Exposure to opioids through legal prescriptions is thought to contribute to this opioid crisis. Another exposure to prescribed opioids may occur during inpatient hospitalization, and inpatients may be at risk for an extreme version of this exposure, opioid poisoning. Despite our current understanding of the opioid epidemic, limited data exists on the occurrences of opioid misuse in vulnerable populations such as the hospitalized trauma patient. 

Methods:  This is a retrospective multi-institutional cohort study utilizing data from the 2008-2014 Nationwide Inpatients Sample, Healthcare cost and utilization Project, and Agency for Healthcare Research and Quality database. Patients were included in the study if they were 18 years or older and had a primary ICD-9 diagnosis of trauma and any diagnosis of opioid poisoning. Trauma characteristics were further evaluated using the ICDPIC module. Costs were determined using cost-to-charge ratio files. Unadjusted and adjusted analyses were performed and all reported values represent weighted estimates. 

Results: Overall, 9,314,780 trauma patients were included in this analysis, of which, 2,970 (0.03%) suffered from opioid poisoning. The rates of opioid poisonings during these years have remained unchanged over the study period (p=0.21). In multiple logistic regression analysis, ISS >15 (OR 0.58, 95% CI 0.43-0.79, p=0.001), increasing age (OR 0.98, 95% CI 0.98-0.99, p<0.001), and isolated extremity injuries (OR 0.6, 95% CI 0.46-0.79, p<0.001) were associated with lower odds ratio of opioid poisoning. In contrast, female gender (OR 1.5, 95% CI 1.3-1.9, p<0.001) was associated with higher risk. Injury characteristics of patients suffering from opioid poisoning are demonstrated in Figure 1. Trauma patients who suffer from opioid poisonings are hospitalized longer (Mean=6.6, SD=6.6 vs. Mean=5.2, SD=6.8 p<0.001) and have more costly hospitalizations (Mean=$19,202, SD=$22,687 vs. Mean=$16,248, SD=$22,572 p<0.001).

Conclusion: Despite focused efforts to raise awareness and reduce opioid misuse, inpatient opioid poisonings occurred in approximately 3,000 trauma patients over the study period. These risks are higher in female patients, those with minor injuries, and those with non-extremity injuries, which is a group likely at risk of discharge with opioids. This suggests that a pattern of opioid misuse may begin with a patient’s initial inpatient hospitalization for trauma. Opioid stewardship for trauma patients is more than just an outpatient responsibility, and likely begins during the initial inpatient hospitalization. 

 

14.17 Disaster Response In The Operative Suite

Posted on January 18, 2018

R. Frazee1, H. Papaconstantinou1, R. Frazee1  1Scott & White Healthcare,Surgery,Temple, Texas, USA

Introduction:  Physical disasters to the operative suite can occur through severe weather, power outages, fires, and structural failure.  Advanced planning permits a coordinated response to physical disasters, and should be a part of hospitals’ emergency response planning.  Loss of services can severely impact patient care and produce financial shortfalls.

Methods:  A retrospective review of a flood in at a 25-room hospital operative suite was performed.  Patient safety, operative volume, disaster team response, and overall impact to patient care were analyzed.

Results:  

On May 10, 2017, during the night shift cleaning of the operative suite, a ceiling fire sprinkler was dislodged.  One hundred gallons of stored water/minute was released for 48 minutes before the shut off valve was located and closed.  Eleven operating rooms sustained flood damage and were deemed unsafe for usage.  The disaster plan was activated and the “command center” opened. Physician, nursing, administrative, and physical plant leadership joined in the command center to coordinate the response as follows:

Containment:  Physical barriers were placed between involved and uninvolved operating rooms to contain water, humidity, and potential infectious contaminants.  Ongoing monitoring of rooms occurred to assure patient safety.

Communication:  Patients scheduled for elective surgery and their surgeons were contacted before their report time to inform them of the situation.  They were given the option to reschedule for another day or proceed with a revised report time. 

Cooperation:  A revised schedule utilizing the 14 remaining functional rooms was developed.  When possible, hospital outpatient procedures were moved to our on-campus outpatient surgery center.  A second shift of scheduled cases was developed to accommodate the volume of cases with fewer operating rooms.  An elective Saturday schedule was added to address unmet surgical volume.

Clean-up:  Water removal and drying devices were immediately implemented.  Assistance from a commercial restoration company and consultants was utilized.  Damaged structural elements were removed and reconstructed.  Infectious disease experts performed culture analysis to assure patient safety.

After six days of round the clock clean-up, the damaged rooms were repaired and met monitoring standards for patient use.  All postponed cases had been accommodated with the expanded hours and weekend schedule.

Conclusion:  Prior planning is essential to meet the challenges of physical disaster in the operative suite.  A command center with defined leadership roles permits a rapid response to minimize the impact of these events.  
 

15.01 Rigid Sigmoidoscopy is Diagnostically Superior to CT for Penetrating Rectal Injury

Posted on January 18, 2018

M. J. Chaudhary1, R. Smith2, G. Victorino1  1UCSF-East Bay,Surgery,Oakland, CA, USA 2Emory University,Surgery,Atlanta, GA, USA

Introduction:
Computed tomography (CT) is commonly used to evaluate penetrating pelvic organ injury. Rigid sigmoidoscopy may be used as an adjunct in identifying penetrating rectal injury but its sensitivity compared to CT remains unknown. The purposes of this study were: (1) to determine the clinical utility of pelvic computed tomography (CT) in identifying the need for operative intervention after penetrating pelvic trauma, and (2) to determine if rigid sigmoidoscopy, cystogram or retrograde urethrogram improve the diagnostic yield of penetrating pelvic organ injury.

Methods:
We conducted a retrospective review of the trauma registry at our university-affiliated trauma center between January 1999 and December 2016. All patients with penetrating pelvic trauma, who had a CT of the pelvis prior to any potential operative intervention, were included. Operative reports were used to calculate the sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) for CT and rigid sigmoidoscopy in identifying pelvic organ injury.

Results:
During the study period, 160 patients were treated for penetrating pelvic trauma. Overall mortality after penetrating pelvic injury (including combined body compartment trauma) was 16% (26/160). Bladder injuries comprised the majority of injuries (n=86, 54%), followed by injuries to the ureter, blood vessels, and rectum, respectively. Out of the 160 patients with penetrating pelvic trauma, 37% (59/160) underwent preoperative CT scans and 19% (31/160) underwent rigid sigmoidoscopy. A comparison of the sensitivity, specificity, PPV, and NPV of CT and rigid sigmoidoscopy for penetrating rectal injury is attached.

Rigid sigmoidoscopy identified 71% (5/7) of rectal injuries missed by CT. For the remaining two missed injuries, in one case rigid sigmoidoscopy failed to identify an injury and in the other rigid sigmoidoscopy was not performed. CT had a sensitivity of 66%, specificity of 98%, PPV of 67% and NPV of 95% for bladder injury. Cystogram or retrograde urethrogram (RUG) was performed in 3% (5/160) of patients. Cystogram and RUG used in isolation or combination had 100% sensitivity, specificity, NPV and PPV for bladder injury. However, these adjuncts did not identify any injuries missed on CT.

Conclusion:
CT of the pelvis in clinically suitable patients with penetrating pelvic trauma has a low sensitivity and NPV for diagnosing operatively significant rectal or bladder injury. Rigid sigmoidoscopy increases the diagnostic yield for penetrating rectal injury requiring operative intervention. When clinical concern for rectal injury exists following penetrating trauma in the absence of CT findings, rigid sigmoidoscopy is warranted. 

14.14 The Impact of Socieoeconomics in Firearm Related Injury

Posted on January 18, 2018

K. L. Haines1, C. Warner-Hillard1, S. Agarwal1, H. Jung1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  We sought to evaluate the impact of socioeconomic status on mortality in firearm related mortality.

Methods: The National Trauma Databank was queried for all firearm related injury patients from 2010-2015. Pearson-Chi2 univariate regressions were run on patient comorbidities to determine what patient factors significantly contributed to mortality. Multivariate logistic regression models to stratify incidence and outcomes for all patients with firearm related injuries were created using significant covariates, age, gender, and injury severity. Subgroup logistic models were also created for self-inflicted, accidental, and assault injuries.

Results: There were 170,140 firearm related injuries in that time period. The firearm mortality rate was 2.17%. The incidence of firearm related injury was higher in younger patient (18-45 years, n=126,267, 74%). Younger patients had a higher had a significantly higher mortality rate than older patients on chi2analysis (p<0.001). However, when controlling for other risk factors, age was a significant, independent risk factor for mortality (p<0.001).

Uninsured patients who sustained a firearm related assault injury and self-inflicted injury were more likely to die than patients with any other form of insurance (OR 1.4, OR1.2, p < 0.001; respectively). Race did not impact mortality except in Black patients after firearm related assault injuries (OR 0.76 p<0.001). Patients with previously diagnosed psychiatric illnesses were less likely to die from self-inflicted GSW. Socioeconomic status, race and ethnicity did not affect mortality for accidental firearm related injuries.  Self-inflicted firearm related injury patients were eight times more likely to die as compared to accidental or assault injury patients (CI 3.3-19.7).

Conclusion: While firearm related injury is more prevalent in younger patients, age is an independent risk factor for mortality. Uninsured firearm related assault and self-inflicted injury patients are more likely to die than those patient with any form of insurance.
 

14.13 The Effect of Race and Insurance Status on Bicycle Trauma Outcomes in Adults

Posted on January 18, 2018

H. Chen2, K. Haines1, T. Zens1, B. Brummeyer2, S. Agarwal1, J. E. Scarborough1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Madison, WI, USA 2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:
Race and insurance status have been shown to predict outcomes in pediatric bicycle traumas. It is unknown how these factors influence outcomes in adult bicycle traumas. This study aims to evaluate the association, if any, between race and insurance status with mortality in adults. 

Methods:
This retrospective cohort study used the National Trauma Data Bank (NTDB) Research Data Set for the years 2013-2015. Multivariate logistic regression models were used to determine the independent association between patient race and insurance status on helmet use and on outcomes after hospitalization for bicycle-related injury. These models adjusted for demographic factors and comorbid variables. When examining the association between race and insurance status with outcomes after hospitalization, injury characteristics were also included.

Results:
A study population of 45,063 met the inclusion and exclusion criteria. Multivariate regression demonstrated that black adults and Hispanic adults were significantly less likely to be helmeted at the time of injury than white adults [adjusted odds ratio of helmet use for blacks 0.25 (95% CI 0.22-0.28) and for Hispanics 0.33 (95% CI 0.30-0.36) versus whites]. Helmet usage was also independently associated with insurance status, with Medicare-insured patients [AOR 0.51 (95% CI 0.47-0.56) versus Private-insured patients], Medicaid-insured patients [AOR 0.18 (95% CI 0.17-0.20)], and Uninsured patients [AOR 0.29 (95% CI 0.27-0.32)] being significantly less likely to be wearing a helmet at the time of injury compared to Private-insured patients.  Although patient race was not independently associated with hospital mortality among adult bicyclists, we found that Uninsured patients had significantly higher odds of mortality [AOR 2.02 (AOR 1.31-3.12] compared to Private-insured patients.

Conclusion:
Minorities and under-insured patients are significantly less likely to be helmeted at the time of bicycle-related trauma when compared to white patients and those with private insurance.  Public health efforts to improve the utilization of helmets during bicycling should target these subpopulations.
 

14.10 A 5-Year Analysis of a Hospital-Based Violence Recovery Program

Posted on January 18, 2018

E. A. Bryant1, M. Castillo-Angeles1, D. Nehra1, M. Chadwick1, R. Ramsis1, L. A. Benedict2, R. Askari1, A. Salim1  1Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care, Department Of Surgery,Boston, MA, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:  Hospital based violence intervention programs have been established in several major cities to address recurrent violence related trauma admissions. Our hospital established a violence recovery program (VRP) in 2012 to provide in hospital and community case management for victims of violence.  The aim of this study was to assess the short term performance of our program and to identify the characteristics of patients who actively utilized the resources that were offered. 

Methods:  This is a single-center retrospective study that includes patients admitted from 2012 to 2016. Data was obtained from the VRP's case management database and the trauma center's Trauma Registry. Participants who were initially approached by the VRP but refused further interventions were classified as "non-users," whereas those who had a minimum of 3 encounters with the VRP were classified as "high-users."  Demographics and injury characteristics were compared between non-users and high-users. Specific services utilized by high-users were examined.

Results: 447 patients met inclusion criteria, of whom 134 (30%) were high-users.  The high-users compared to non-users were younger (p=0.0005), more likely to be black (p<0.001), more likely to have sustained a gunshot wound (p<0.001) and had longer hospital lengths of stay (p<0.001). The service most commonly utilized by the high-users was housing assistance (63%), followed by employment assistance (59%), and safety planning (41%).

Conclusion: Over a five year period, our VRP provided extensive assistance to 30% of eligible patients.  We did not identify any modifiable factors differentiating high-users from non-users. Further work is ongoing to identify barriers to utilization of VRP services in an effort to improve utilization and also to evaluate longer-term outcomes.

 

14.11 Do Racial Disparities Play a Role in Failure to Rescue in Emergency General Surgery?

Posted on January 18, 2018

M. Castillo-Angeles1, D. Metcalfe2, S. L. Nitzschke1, A. H. Haider1, A. Salim1, J. M. Havens1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2University Of Oxford John Radcliffe Hospital,Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences,Oxford, OXFORD, United Kingdom

Introduction: Failure to rescue (FTR) is an emerging quality metric that has been shown to be sensitive to differences in healthcare quality. Racial and socioeconomic disparities have been previously described in the surgical setting, but not in a particularly high-risk population such as Emergency general surgery (EGS) patients. This study sought to evaluate for disparities in FTR within the EGS population.

Methods: This is an observational study using the National Inpatient Sample (NIS) 2012-2013; the largest all-payer inpatient database in the United States. The inclusion criteria were all inpatients that underwent one of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Outcomes were Serious Adverse Events (SAE), in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed a SAE). Logistic multivariable regression models were used to adjust for patient- (age, sex, race, payer status, Charlson comorbidity index) and hospital-level (hospital size and location) characteristics. A subgroup analysis was performed comparing the outcomes between high-risk (partial excision of large intestine, excision of small intestine, control of hemorrhage and suture of ulcer of stomach or duodenum, lysis of peritoneal adhesions and laparotomy) and low-risk (appendectomy and cholecystectomy) procedures.

Results: A weighted total of 1.1 million EGS admissions were identified; 150,000 (13.8%) developed a SAE and 15,000 died, giving an overall FTR rate of 10%. Patients with public insurance (adjusted odds ratio 1.29, 95% CI 1.24 – 1.34) and uninsured patients (aOR 1.09, 1.02-1.16) were significantly more likely to die than those with private insurance. In both the unadjusted and adjusted analyses, Black patients had higher odds of a SAE (14.9% versus 17.3%, p<0.001; adjusted odds ratio 1.39, 95% CI 1.33-1.45) when compared to White patients. However, race was not a risk factor for FTR (aOR 0.87, 0.85-1.00). Publicly insured and uninsured patients had higher odds of SAE (aOR 1.29, 1.24-1.34 and aOR 1.09, 1.02-1.16, respectively). Publicly insured patients had increased adjusted odds of FTR when compared with privately insured patients (aOR 1.31, 1.13-1.52) (Table 1). Subgroup analysis between high- and low-risk procedures showed similar results.

Conclusion: Insurance status, but not race, is an independent risk factor for FTR in a representative population of patients undergoing EGS.  Race was determined a risk factor for developing SAEs. FTR partially explains worse outcomes for publicly insured and uninsured EGS patients. FTR is a complex problem and requires prospective studies for more in-depth analysis of this important quality measure.

 

14.12 Insurance Status and Race Affect Treatment and Outcome of Severity Stratified Traumatic Brain Injury

Posted on January 18, 2018

B. P. Nguyen1, K. Haines1, T. Zens1, C. Warner-Hillard1, S. K. Agarwal1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Madison, WI, USA

Introduction:

Socioeconomic status and race has been shown to increase the chance of being afflicted by a Traumatic Brain Injury (TBI) and result in worse post-hospitalization outcomes. There is a paucity of data on how severity of TBI mediate these treatment and outcome factors. The goal of this study is to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed based on insurance status and race/ethnicity throughout the range of TBI severity.

Methods:

This was a retrospective cohort study using the National Trauma Data Bank (2012-2015) analyzing patients with closed head injuries. Univariate and multivariate logistic/linear regression models were performed to determine the impact of race/ethnicity and insurance status on in-hospital mortality, discharge to inpatient rehabilitation, LOS, and TBI procedures performed in groups stratified by head Abbreviated Injury Scale (AIS).

Results:

We analyzed 708,261 TBI patients 76.6% white, 30% private insurance, 13% uninsured, the distribution of severity was 1.3% AIS of 1, 28.3% of AIS of 2, 30.1% of AIS of 3, 30.4% of AIS of 4, 9.9% of AIS of 5. As compared to privately insured patients, uninsured patients experienced greater mortality with increasing AIS, which began from an AIS of 3 (OR = 1.01, p < 0.001) and was the highest at an AIS of 5 (OR = 1.11, p < 0.001). As compared to privately insured patients, uninsured patients were less likely to be discharged to inpatient rehabilitation with increasing AIS as seen beginning from an AIS of 2 (OR = 0.98, p < 0.001) to an AIS of 5 (OR = 0.84, p < 0.001). As compared with white patients, black patients had a longer LOS as their AIS increased, this disparity started at an AIS of 2 (0.16 days, p < 0.001) and increasing to the longest LOS at an AIS of 5 (2.44 days, p < 0.001). As compared with non-Hispanic patients, Hispanic patients had a longer LOS with increasing AIS starting with an AIS of 2 (0.11 days, p < 0.001) increasing to the longest LOS at an AIS of 5 (1.124 days, p < 0.001). Compared with privately insured patients, Medicaid patients had a longer LOS in all AIS stratifications starting from an AIS of 1 (0.55 days, p < 0.001) increasing to the longest LOS at an AIS of 5 (5.52 days, p < 0.001).

Conclusion:

Disparities lead to differences in mortality, procedures performed, and discharge to inpatient rehabilitation for uninsured patients in higher ranges of TBI severity. Also, disparities lead to differences to LOS for black, Hispanic and Medicaid patients throughout the entire spectrum of TBI severity. The most vulnerable populations and minorities with the highest TBI severity seem to have the greatest disparities in treatment and outcome factors.

14.07 Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injuries

Posted on January 18, 2018

L. M. Woldanski1, K. Haines1, T. Zens1, S. Agarwal1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction: Racial, ethnic, and socioeconomic disparities exist in trauma patients. Management of blunt splenic injuries (BSI) can vary from splenectomy, embolization, or non-operative management. This study assessed the effect of race and insurance status on treatment plans and outcomes in blunt splenic trauma.  

Methods:  The National Trauma Data Bank was used to study on patients aged 15-89 with BSI from 2013-2015. Patients with abbreviated injury scores greater than 2 in non-abdominal areas were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using Chi-Square tests, and those with significant associations were used in multivariate regression models for each outcome of interest to control for confounding variables.

Results:We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality (OR 1.6, p>0.001), more splenic operations (OR 1.6, p<0.001), and were less likely to have non-operative management (OR 0.63, p<0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave AMA. (OR 0.35, OR 0.33; p<0.001). Blacks and Hispanics had higher mortality (OR 1.5; p=0.035, p=0.029 respectively). Blacks had more splenic operations (OR 1.23, p=0.03) and were 0.5 times less likely to receive angioembolization (p<0.001), while Hispanics had less splenic operations (OR 0.81, p=0.032).

Conclusion:Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race affect surgical treatment plans and mortality, particularly for uninsured, Black and Hispanic patients. 

 

14.08 Risk Factors for Trauma Readmissions: Everything Matters

Posted on January 18, 2018

S. O. Dennis1, J. K. Canner2, D. T. Efron2, E. R. Haut2, J. V. Sakran2, K. A. Stevens2, C. Jones2  1East Carolina University Brody School Of Medicine,Greenville, NC, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Trauma readmission rates are used to assess quality of care, hence identifying risk factors for readmission has become a priority. Prior studies have had disparate results and result in few predictors of readmission. We sought to examine a large data set to determine risk factors increasing odds of readmission after trauma.

Methods:  We used Maryland’s Health Services Cost Review Commission (HSCRC) Inpatient Data Set to identify injured patients admitted to acute care hospitals from 2013-2015; the HSCRC includes unique identifiers to track patient admissions statewide across institutions. We compared patients readmitted within 30 days of discharge from an initial trauma admission to those not readmitted. We included variables previously identified as potentially affecting readmission (Table). After univariable comparison, we included potentially statistically significant (p < 0.1) factors not collinear with others in a multiple logistic regression analysis to identify those independently associated with readmission (p < 0.05).

Results: We identified 300,925 index trauma admissions. 50,309 (17%) were followed by a readmission; 14,724 (29%) of these were admissions to a different hospital. All variables evaluated except injury mechanism were statistically significant on univariable and multivariable analyses, each independently associated with readmission risk (Table). For this complex model, the area under the receiver operating characteristic curve is only 0.61, suggesting even the inclusion of all variables is inadequate for predicting readmission. 

Conclusion: These data demonstrate a small number of variables will not adequately predict readmissions; rather, a broad swath of variables is needed to quantify readmission risk. Future formulations should use a wider range of available data and may need to be combined with advanced techniques to determine a patient’s individual risk of readmission.

14.09 Comparison of Penetrating Colon Trauma Outcomes between African American and Caucasian Men

Posted on January 18, 2018

S. J. Skube1, B. Lindgren1, Y. J. Fan1, S. Jarosek1, G. B. Melton1, M. D. McGonigal1,2, M. R. Kwaan1  1University Of Minnesota,Minneapolis, MN, USA 2Regions Hospital,St. Paul, MN, USA

Introduction:
The colon is the second most commonly injured organ in patients sustaining penetrating abdominal trauma. The standard of care for colon injury has evolved from repair with fecal diversion to primary anastomosis or primary repair. Previous studies have demonstrated a ten-fold higher rate of penetrating abdominal trauma in African American men. Racial disparities have been both published and disputed in trauma patient mortality, functional outcomes, and rehabilitation. The aim of this project was to assess racial disparities in the surgical care of trauma patients with penetrating colon trauma by evaluating differences in stoma formation and post-operative outcomes.

Methods:
We identified men over the age of 14 in the National Trauma Data Bank between 2010-2014 who had operative intervention for colon trauma. Patients with rectal injury and those transferred to another facility were excluded. The primary outcome was stoma formation with secondary outcomes including post-operative morbidity and mortality. A multivariate logistic regression was performed for ostomy formation controlling for race and significant co-variates.

Results:
Our query resulted in identification of 7,324 men with penetrating colon trauma requiring operative intervention (4916 African American, 2408 Caucasian). 18.5% of Caucasian patients and 19.6% of African American patients underwent fecal diversion with stoma formation (p = 0.283). African American patients were younger with a median age of 27 (range 15-86) versus 35 (range 15-88), more likely to self-pay (37.1% versus 29.9%), and more likely to be injured by firearm (88.3% versus 70.2%). African American patients had less overall post-operative morbidity (50.7% versus 63.0%, p = <0.001). On multivariate analysis, the odds of receiving an ostomy for African American vs Caucasian patients was similar (odds ratio=0.95, 95% CI: 0.83-1.10). Factors associated with stoma formation in penetrating colon trauma are shown in Table 1.

Conclusion:
This analysis did not demonstrate a difference in stoma formation between African American and Caucasian men. Multivariate analysis confirmed expected findings that trauma severity (firearm, GCS, ISS) increased the odds of receiving ostomy. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to these disparities demonstrated in other healthcare settings.
 

14.05 The Only Color that Matters is Green

Posted on January 18, 2018

K. L. Haines1, T. Zens1, C. Warner-Hillard1, H. Jung1, S. Agarwal1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: To date, many studies have shown both racial and socioeconomic disparities exist with regard to outcomes in trauma. This study evaluates all trauma patients over a 3-year period to determine what factors contribute to their mortality, controlling for injury severity. 

Methods: All trauma patients ≥ 15 years old from 2012 to 2015 were queried from The National Trauma Data Bank. Pearson Chi2 and multivariate logistic regression models for mortality were performed controlling for patient age, gender, co-morbidities, injury severity (ISS), insurance, race, and ethnicity. 

Results: When evaluating 2,921,790 patients, uninsured patients are 2.2 times more likely to die as compared to insured patients (OR 2.2, p<0.0001). Patients with Medicare are 1.5 times more likely to die, government-insured patients were 2.0 times, Medicaid 1.2 times, and auto insurance 1.4 time more likely to die than privately insured patients (p<0.0001). African Americans (p=0.99, American Indians (p=0.86), and Hispanics p=0.26) controlling for socioeconomic status had the same mortality risk as Caucasian patients. History of bleeding disorder, current chemotherapy or disseminated cancer, diabetes, cirrhosis, respiratory disease, history of MI, peripheral vascular disease, CHF, renal failure, esophageal varices, history of CVA all significantly contributed to mortality and were controlled for in this model (p<0.05). ISS (OR 1.1), gender (OR 1.4), age (OR 1.0), and alcohol use (OR 1.2) significantly correlated with mortality in this regression (p<0.001). 

Conclusion: When analyzing all trauma patients, every patient despite their injury severity, medical comorbidities, race and ethnicity was more likely to die if they did not have private or worker’s compensation insurance. Patients identified as African American, American Indian, or Hispanic had identical outcomes as Caucasian patients. Currently, mortality in trauma directly correlates with financial wellbeing.

 

14.06 Factors Associated with Secondary Over-triage in Trauma Patients

Posted on January 18, 2018

P. P. Parikh1, P. Parikh2, J. A. Pestana2, J. V. Sakran3  1Wright State University,Department Of Surgery, Boonshoft School Of Medicine,Dayton, OH, USA 2Wright State University,Department Of Biomedical, Industrial And Human Factors Engineering,Dayton, OH, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction: Transfer of the injured patient is centered on improving outcomes. However, at times minimally injured patients are also transferred to Level I/II trauma centers resulting in secondary over-triage (SO). SO is a resource-sensitive challenge to trauma centers. The purpose of this study is to evaluate the burden of SO in a state-wide trauma system and identify factors that may lead to a SO.

Methods: The Ohio Department of Public Safety trauma and EMS registries were used to identify patients during 2008–2012. The inclusion criteria were: patients taken to Level III/non-trauma center (NTC) from the scene, ISS<15, and discharged alive. The subgroup of patients subsequently transferred to Level I/II trauma center, who had no surgical intervention, and were discharged alive within 48 hours of admission were analyzed. This subgroup was defined as SO and the remainder were included in the non-transferred group. The SO group was analyzed descriptively. Multivariable logistic regression was then used to identify factors associated with SO. The analysis included patient level factors (demographics), clinical factors (Glasgow comma scale, respiratory rate, systolic blood pressure, injury type, and pre-existing conditions), and insurance type.  We also included system level factors, such as number of LI/LII in the region and EMS reasons for selecting the first facility from the field.

Results:A total of 34,494 trauma patients were identified, and 7,881 (22.85%) patients met the inclusion criteria, out of which 965 (12.2%) met our definition of SO. The median age in the SO group was 40 years and majority (70%) of these patients were discharged home. After adjusting for age, gender, pre-existing conditions, and insurance type, the presence of penetrating injury (adjusted odds ratio [AOR] 1.71; 95% CI, 1.12-2.60; P = 0.01) and burns (AOR 2.82; 95% CI, 1.35-5.76; P = 0.006) were associated with SO (model area under the curve [AUC]=0.88). Further, system level factors, such as number of LI/II in the region (>2 vs ≤2) significantly impacted SO (AOR 1.30; 95% CI, 1.11-1.54; P < 0.001). The reason for destination choice, specifically closest facility (AOR 1.67; 95% CI, 1.40-2.00; P <0.0001) and use of on field trauma triage protocol (AOR 2.20; 95% CI, 1.70-2.85; P <0.0001), significantly increased the likelihood of SO. 

Conclusion:A proportion of minimally injured patients are subject to SO that impact regional and statewide trauma system utilization. System level factors, such as number of major trauma centers in the region and taking patients to the closest facility, significantly impacts SO. Subsequent investigation to identify optimal distribution of trauma centers is, therefore, critical. Targeted education and outreach to EMS personnel on the interpretation of triage protocol and further guidance to the NTC on when to transfer an injured patient may further reduce SO.

 

14.04 Racial Disparities in Post-Discharge Healthcare Utilization after Trauma

Posted on January 18, 2018

S. Chun Fat1, J. P. Herrera-Escobar1, S. S. Al Rafai1, Z. Hashmi1, M. Villanyi2, J. Nabi1, C. Velmahos3, K. Brasel4, G. Kasotakis2, A. Salim1, A. H. Haider1, D. Nehra1  1Brigham And Women’s Hospital,Boston, MA, USA 2Boston University,Boston, MA, USA 3Massachusetts General Hospital,Boston, MA, USA 4Oregon Health And Science University,Portland, OR, USA

Introduction:  Previous studies have shown that minority patients have worse in-hospital outcomes than white/Caucasian (WC) patients after trauma. However, very little is known about racial differences in utilization of post-discharge healthcare services after trauma. The purpose of this study is to determine if there is a difference in utilization of healthcare resources between black/African American (BAA) and WC trauma patients after discharge from the hospital.

Methods:  Adult trauma patients with an Injury Severity Score (ISS) ≥9 were identified using the institutional trauma registry of three Level I trauma centers and contacted 6- or 12-months post-injury to participate in a telephone interview. Participants were asked about 1) utilization of post-discharge services (inpatient and outpatient rehabilitation, physical/occupational therapy and speech/language therapy), 2) emergency department (ED) visit and 3) outpatient visits for injury related issues. Univariate analyses were performed using chi-squared test. To address for potential confounding, coarsened exact matching (CEM) algorithm was used to match WC and BAA patients on age, sex and Injury Severity Score (ISS). Conditional logistic regression was then used to compare WC versus BAA patients in terms of post-discharge healthcare utilization.

Results: A total of 694 patients were followed. This included 128 BAA patients who were then matched to 566 WC patients. The mean age was 64 years (SD: 20.4) for WC and 44 years (SD: 19.6) for BAA. Mean ISS was not significantly different between groups (14 for WC vs 15 for BAA, p=0.142). Unadjusted analyses revealed that compared to WC patients, BAA patients were less likely to use post-discharge services (80% vs 63% p: <0.001) and had fewer injury-related outpatient visits (42% vs 33% p: 0.054) after discharge. Furthermore, BAA patients were more likely to visit the emergency department for injury-related issues compared to WC (15% vs 8% p: 0.023). After coarsened exact matching, we found significant differences in utilization of healthcare resources post-discharge between the two racial groups (Figure).

Conclusion: This study demonstrates the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients. This may partially explain previously reported discrepancies in long-term patient reported outcomes between WC and BAA patients. Interventions aimed at ensuring equitable access to post discharge resources are needed. 

 

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