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Context: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown.Objective: To evaluate the association between trauma center volume and outcomes of trauma patients.Design: Retrospective cohort study.Setting: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study.Patients: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998.Main Outcome Measures: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (Results: After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002-0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P =.50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26-0.93) vs low-volume centers. No benefit was observed in patients without coma (P =.05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91-5.70 days]).Conclusions: Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes. [ABSTRACT FROM AUTHOR]

Context: Despite calls for wider national implementation of an integrated approach to trauma care, the effectiveness of this approach at a regional or state level remains unproven.Objective: To determine whether implementation of an organized system of trauma care reduces mortality due to motor vehicle crashes.Design: Cross-sectional time-series analysis of crash mortality data collected for 1979 through 1995 from the Fatality Analysis Reporting System.Setting: All 50 US states and the District of Columbia.Subjects: All front-seat passenger vehicle occupants aged 15 to 74 years.Main Outcome Measures: Rates of death due to motor vehicle crashes compared before and after implementation of an organized trauma care system. Estimates are based on within-state comparisons adjusted for national trends in crash mortality.Results: Ten years following initial trauma system implementation, mortality due to traffic crashes began to decline; about 15 years following trauma system implementation, mortality was reduced by 8% (95% confidence interval [CI], 3%-12%) after adjusting for secular trends in crash mortality, age, and the introduction of traffic safety laws. Implementation of primary enforcement of restraint laws and laws deterring drunk driving resulted in reductions in crash mortality of 13% (95% CI, 11%-16%) and 5% (95% CI, 3%-7%), respectively, while relaxation of state speed limits increased mortality by 7% (95% CI, 3%-10%).Conclusions: Our data indicate that implementation of an organized system of trauma care reduces crash mortality. The effect does not appear for 10 years, a finding consistent with the maturation and development of trauma triage protocols, interhospital transfer agreements, organization of trauma centers, and ongoing quality assurance. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence of handgun ownership among urban high school youth and investigate associations with socioeconomic status, ethnicity, and deviant behaviors.Design: Survey of half of the Seattle, Wash, public high schools, which enroll 50% of the school district's 11th-grade students (N = 970).Main Outcome Measures: Self-reports of handgun ownership, perceived access to handguns, racial/ethnic identity, social status (Hollingshead's Two Factor Index of Social Position), and social deviance (Seattle Self-Report Instrument) were determined.Results: Thirty-four percent of the students reported easy access to handguns (47% of males, 22% of females) and 6.4% reported owning a handgun (11.4% of males, 1.5% of females). Reported firearm experiences indicated a high rate of handgun utilization: 33% of handgun owners had fired at someone, 9.7% of female students reported a firearm homicide or suicide in family members or close friends, and 6% of male students reported carrying a handgun to school sometime in the past. Handgun ownership was more common among students who reported deviant behaviors. Adjusting for age, gender, and racial/ethnic group and controlling for covariation among the problem behaviors, gang membership (odds ratio [OR], 8.8; 95% confidence interval [CI], 3.7 to 20.8), sentencing by a judge (OR, 4.6; 95% CI, 1.3 to 15.5), selling drugs (OR, 3.7; 95% CI, 1.8 to 7.8), suspension or expulsion from school (OR, 3.5; 95% CI, 1.7 to 7.0), and assault and battery (OR, 2.5; 95% CI, 1.1 to 5.9) were associated with handgun ownership. However, 22% of male handgun owners did not report any of the above behaviors.Conclusion: The availability of handguns to the urban high school students surveyed is pervasive, and it is not limited to high-risk groups. [ABSTRACT FROM AUTHOR]

To assess the effect of a community-wide bicycle helmet campaign on helmet use, we observed 9827 children riding bicycles at sites in high-, middle-, and low-income census tracts in Seattle, Wash (intervention city), and Portland, Ore (control city); observations were made during 2-week intervals before and 4, 12, and 16 months after the campaign's start. Helmet use increased from 5.5% before the campaign to 15.7% afterward in Seattle and from 1.0% to 2.9% in Portland. Strong associations were found between helmet use and white compared with black or other race; riding geared vs nongeared bicycles; riding at playgrounds, in parks, or on bicycle paths vs on city streets; and riding with adults or other children compared with riding alone. The proportions of helmet wearers, adjusted for these variables, increased from 4.6% to 14.0% in Seattle and from 1.0% to 3.6% in Portland, a significantly greater increase in use in Seattle compared with Portland. We conclude that a community-wide bicycle helmet campaign can increase helmet use among children. [ABSTRACT FROM AUTHOR]

The prehospital, emergency department, and in-hospital care of 84 patients who died following a pedestrian- or bicycle-motor vehicle collision in a four-county area was retrospectively reviewed using a systematic, detailed scoring system. The purpose of the study was to examine the effectiveness of an advanced paramedic-regionalized trauma care system and to examine the usefulness of a systematic evaluation tool in identifying preventable and possibly preventable deaths. Among the 84 deaths, one was judged to be preventable and 18 possibly preventable. The one preventable death occurred in the emergency department, while the possibly preventable deaths more commonly occurred after 48 hours and were due to central nervous system injury, sepsis, and multiple organ failure. Prolonged prehospital and emergency department time and failure to establish an airway were the most common problems identified as contributing to fatal outcome. The use of explicit criteria was demonstrated to be an effective addition to the analysis of trauma care systems. [ABSTRACT FROM AUTHOR]

Nearly half of all trauma beds are occupied by patients who were injured while under the influence of alcohol. Alcoholism plays such a significant role in trauma that efforts to reduce injury recurrence are unlikely to be successful if it remains untreated. An injury requiring hospitalization creates a unique opportunity to intervene and to motivate patients to alter their drinking behavior, thereby making trauma centers ideal sites to implement an alcohol screening, intervention, and referral program. However, despite emphasis on injury control and prevention, little has been done to incorporate alcohol intervention programs into care of the injured patient. Effective means of intervention exist that are consistent with the time, financial, and staffing constraints of trauma centers, and they should be implemented. [ABSTRACT FROM AUTHOR]

Objective: To determine if a commonly used violence prevention curriculum, Second Step: A Violence Prevention Curriculum, leads to a reduction in aggressive behavior and an increase in prosocial behavior among elementary school students.Design: Randomized controlled trial.Setting: Urban and suburban elementary schools in the state of Washington.Participants: Six matched pairs of schools with 790 second-grade and third-grade students. The students were 53% male and 79% white.Intervention: The curriculum uses 30 specific lessons to teach social skills related to anger management, impulse control, and empathy.Main Outcome Measures: Aggressive and prosocial behavior changes were measured 2 weeks and 6 months after participation in the curriculum by parent and teacher reports (Achenbach Child Behavior Checklist and Teacher Report Form, the School Social Behavior Scale, and the Parent-Child Rating Scale) and by observation of a random subsample of 588 students in the classroom and playground/cafeteria settings.Results: After adjusting for sex, age, socioeconomic status, race, academic performance, household size, and class size, change scores did not differ significantly between the intervention and control schools for any of the parent-reported or teacher-reported behavior scales. However, the behavior observations did reveal an overall decrease 2 weeks after the curriculum in physical aggression (P=.03) and an increase in neutral/prosocial behavior (P=.04) in the intervention group compared with the control group. Most effects persisted 6 months later.Conclusions: The Second Step violence prevention curriculum appears to lead to a moderate observed decrease in physically aggressive behavior and an increase in neutral and prosocial behavior in school. [ABSTRACT FROM AUTHOR]

Objectives: To examine the protective effectiveness of bicycle helmets in 4 different age groups of bicyclists, in crashes involving motor vehicles, and by helmet type and certification standards.Research Design: Prospective case-control studySetting: Emergency departments (EDs) in 7 Seattle, Wash, area hospitals between March 1, 1992, and August 31, 1994.Participants: Case subjects were all bicyclists treated in EDs for head injuries, all who were hospitalized, and all who died at the scene. Control subjects were bicyclists treated for nonhead injuries.Main Results: There were 3390 injured bicyclists in the study; 29% of cases and 56% of controls were helmeted. Risk of head injury in helmeted vs unhelmeted cyclists adjusted for age and motor vehicle involvement indicate a protective effect of 69% to 74% for helmets for 3 different categories of head injury: any head injury (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.26-0.37), brain injury (OR, 0.35; 95% CI, 0.25-0.48), or severe brain injury (OR, 0.26; 95% CI, 0.14-0.48). Adjusted ORs for each of 4 age groups (<6 y, 6-12 y, 13-19 y, and > or = 20 years) indicate similar levels of helmet protection by age (OR range, 0.27-0.40). Helmets were equally effective in crashes involving motor vehicles (OR, 0.31; 95% CI, 0.20-0.48) and those not involving motor vehicles (OR, 0.32; 95% CI, 0.20-0.39). There was no effect modification by age or motor vehicle involvement (P=.7 and P=.3). No significant differences were found for the protective effect of hard-shell, thin-shell, or no-shell helmets (P=.5).Conclusions: Bicycle helmets, regardless of type, provide substantial protection against head injuries for cyclists of all ages involved in crashes, including crashes involving motor vehicles. [ABSTRACT FROM AUTHOR]

Context: Approximately 10 million cars with automatic shoulder belt systems are currently in use in the United States. However, reports on the effectiveness of such restraints have yielded conflicting results.Objective: To determine the effectiveness of automatic shoulder belt systems in reducing the risk of injury and death among front-seat passenger vehicle occupants.Design, Setting, and Subjects: Analysis of data collected from the 1993-1996 National Highway Traffic Safety Administration Crashworthiness Data System on front-seat occupants involved in 25,811 tow-away crashes of passenger cars, light trucks, vans, and sport utility vehicles.Main Outcome Measures: Death and serious injury to specific body areas by use of manual lap and shoulder belts, automatic shoulder belts with manual lap belts, or automatic shoulder belts without lap belts, compared with no restraint use.Results: Use of automatic shoulder belts without lap belts was associated with a decrease in the risk of death vs no restraint use but was not statistically significant for all crashes (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.42-1.06) or for frontal crashes (OR, 0.71; 95% CI, 0.38-1.35) after adjustment for occupant age, sex, vehicle year, air-bag deployment, estimated change in vehicle speed during the crash, and principal direction of force. This association was significantly weaker than the 86% lower risk observed for use of automatic shoulder belts with lap belts (OR, 0.14; 95% CI, 0.07-0.26 vs no restraint; P<.05). Use of automatic shoulder belts without lap belts was associated with an increased risk of serious chest (OR, 2.66; 95% CI, 1.11-6.35) and abdominal (OR, 2.06; 95% CI, 1.004-4.22) injuries for all crashes.Conclusions: These data indicate that improperly used automatic restraint systems may be less effective than properly used systems and are associated with an increased risk of serious chest and abdominal injuries. Given the continued widespread use of these automatic systems, educational programs may be warranted. JAMA. 2000;283:2826-2828 [ABSTRACT FROM AUTHOR]

Context: Since 1989, several states have passed laws that make gun owners criminally liable if someone is injured because a child gains unsupervised access to a gun. These laws are controversial, and their effect on firearm-related injuries is unknown.Objective: To determine if state laws that require safe storage of firearms are associated with a reduction in child mortality due to firearms.Design: An ecological study of firearm mortality from 1979 through 1994.Setting: All 50 states and the District of Columbia.Participants: All children younger than 15 years.Main Outcome Measures: Unintentional deaths, suicides, and homicides due to firearms.Results: Laws that make gun owners responsible for storing firearms in a manner that makes them inaccessible to children were in effect for at least 1 year in 12 states from 1990 through 1994. Among children younger than 15 years, unintentional shooting deaths were reduced by 23% (95% confidence interval, 6%-37%) during the years covered by these laws. This estimate was based on within-state comparisons adjusted for national trends in unintentional firearm-related mortality. Gun-related homicide and suicide showed modest declines, but these were not statistically significant.Conclusions: State safe storage laws intended to make firearms less accessible to children appear to prevent unintentional shooting deaths among children younger than 15 years. [ABSTRACT FROM AUTHOR]