Trauma: Prevention, Mitigation, and Long-term Outcomes
Trauma is the leading cause of death for individuals up to the age of 45 years, and the fourth most prevalent cause of death overall. Emergency General Surgery (EGS) has become a critical national health issue with more cases per year than new diagnoses of cancer or diabetes in the U.S. Trauma and EGS patients are a vulnerable and important population, and research is needed to reduce the human and societal burden of these diseases and improve their outcomes. The Division of Trauma, Burn, Surgical Critical Care and Emergency General Surgery investigates the burden and outcomes of this vulnerable group of patients and aims to implement systems and processes to positively affect these outcomes. Using a patient-first approach, our goal is to define the best evidence to improve short-term and long-term outcomes and reduce the impact on patients and healthcare systems of trauma and emergency general surgery.
Trauma and EGS patients represent unique populations of the most at-risk surgical patients, facing a disproportionate burden of medical errors, complications, and death. Our research focuses on identifying factors that affect mortality and morbidity and evaluating ways to modify those factors to improve outcomes. Our work has helped guide the national research priorities within the fields of emergency general surgery, trauma system optimization, and long-term outcomes after trauma surgery.
Projects
Every year more than three million people are hospitalized from traumatic injuries in the U.S. While 96% of trauma patients survive, many suffer long-term consequences as a result of their injuries. Currently, there is no routine collection of long-term outcomes after injury in the U.S. In an effort to understand what happens to trauma patients after discharge, and to improve their outcomes in the long-term, the Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project was created in 2015. The FORTE project is a multi-institutional research collaboration that collects, analyzes, and interprets long-term patient-centered outcomes after traumatic injury in the U.S.
Co-Investigator: Juan Herrera-Escobar
Traumatic injuries caused more than 200,000 deaths and the loss of 2 million potential life years in the US in 2019. Black, Hispanic, rural, and low-income populations bear a disproportionate burden of injury incidence and mortality. There is an increasing body of evidence suggesting systematic inequities in access to trauma care are a substantial driver of these injury disparities, but current evidence does not identify or quantify specific system-level interventions that might reduce health disparities.
Our proposed work will facilitate equity in trauma care by contextualizing current approaches to trauma systems planning, identifying specific trauma care resources that mediate injury disparities, and identifying actionable strategies to address disparities at the trauma system level. Our partnerships with national trauma leaders will support dissemination and implementation throughout the US.
Principal Investigator: Molly Jarman, PhD, MPH
Funded by the MGB United Against Racism initiative, this project will create a new post-discharge clinical and behavioral health pathway entitled “The NESTS Pathway.” The primary goal of this pathway will be to increase rates of outpatient mental health evaluation for non-English speaking survivors of traumatic injury dealing with symptoms of depression, anxiety, or post-traumatic stress disorder. The NESTS Pathway will apply behavioral economic principles, employ the services of a community health worker, and design a checklist to anticipate and take steps to address systemic barriers to mental health evaluation or treatment. Leveraging the infrastructure previously developed for the FORTE project, the team will contact and screen for mental health conditions of all trauma survivors enrolled in the NESTS Pathway at 6- and 12-months post-injury. This project will be a multidisciplinary and multi-site effort at BWH and MGH with the goal to expand in the near future.
The primary aims of this project are to 1) determine whether use of prehospital opioid analgesia for injured older adults varies by geographic location of injury incident, EMS agency characteristics, and patient characteristics, 2) determine if prehospital pain management interventions are associated with improved health outcomes for injured older adults, 3) determine if prehospital pain management interventions are associated with lower Medicare expenditures for injured older adults during the first year following injury.
Funding Source: National Institute on Aging
Trauma is the leading killer of the world’s non-geriatric adult population and with increasing road traffic injury and rates of interpersonal violence on the rise, health systems worldwide remain unequipped to deal with the influx of the injured. The rates of trauma mortality may be up to 10 times higher in some low-and-middle income country hospitals compared to outcomes in countries with formal trauma systems. While there has been a recent focus on data collection and information systems around trauma, there has been little cross system assessment. This study’s primary aims are to (1) systematically review trauma registry information systems from across the world, (2) understand the barriers and facilitators to consolidating trauma registry data, and (3) assess differences between trauma mortality between regions with and without organized trauma systems.
Millions die of hemorrhage from trauma each year in settings across the world without access to sufficient blood for transfusion. There is an estimated 114 million unit blood shortage in low- and middle-income country (LMIC) blood banks every year. In many rural settings, hundreds of millions live without access to any blood as rural hospitals have either empty blood banks or no blood banks at all. An emerging strategy to address this clinical need is a walking blood bank (WBB), where blood is collected on demand from willing donors, tested using rapid diagnostic testing (RDT), and transfused immediately to a patient. A WBB has not been systematically applied to address chronic shortages in blood availability in LMICs.
Our study consists of three primary aims: (1) characterize the usage and availability of blood products in rural Kenya that could affect or be affected by a community walking blood bank (CWBB), (2) employ qualitative methods to understand frontline clinician and key opinion leader perspectives on the need for, feasibility, and design of a CWBB, and (3) use rigorous laboratory methods to compare the performance of a WBB-based blood testing approach compared to the Kenyan standard.
If we can establish context-appropriate design and safety, this could be an innovative method of bringing blood transfusion to the world’s poorest communities.
Funding Source: Gillian Reny Stepping Strong Center for Trauma Innovation
A series of projects examining how trauma is experienced differently by the most vulnerable in US society. This includes large database work and examines all types of trauma, and takes a more specific look at firearm violence. We examine differences in rates and outcomes, gaps in access, and the cost to the individual and to society.
Emergency general surgery (EGS) patients represent a unique population of the most at-risk surgical patients who face a disproportionate burden of medical errors, complications, and death. Research focuses on identifying factors that affect morbidity and mortality from EGS and evaluating ways to modify those factors to improve outcomes. As a group we have defined the emergency procedures that cause the greatest societal burden. Projects include the creation and testing of a pre-operative checklist and intra-operative huddle specific to EGS patients and developing optimal resource guidelines for institutions that conduct emergency general surgery.
Critically ill patients are often nutritionally compromised, which leads to poorer health outcomes. Research in this area includes description of patients at greatest risk of postoperative aspiration and evaluation of routine screening procedures, characterization of infectious complications in immunosuppressed patients who have received total parenteral nutrition, and a randomized clinical trial to evaluate the safety and effectiveness of an aggressive feeding protocol in critically ill surgical patients.
PI: Reza Askari, MD
Co-PI: Stephanie Nitzschke, MD
Research in this area focuses on improving care for traumatically injured geriatric patients, with an emphasis on integration of palliative care for this population. Projects include evaluating the efficacy of using preoperative muscle volume to predict postoperative outcomes in elderly emergency abdominal surgery patients, assessment of palliative care needs of older adults undergoing surgery, and creation of best practice guidelines for the treatment of older injured patients.
Decreasing the incidence of infection can improve care for all surgical patients, particularly in trauma patients who are already acutely ill. Research in this area includes a retrospective study evaluating surgical interventions for C. Diff infection, a phase 3 clinical trial evaluating the efficacy of a new drug to improve outcomes in patients with necrotizing soft tissue infection (NSTI), and studies exploring the relationship between NSTI and nutrition.
PI: Reza Askari, MD
We study the management and outcomes of many types of traumatic injury in the service of advancing knowledge and improving patient care. This includes genitourinary trauma, rectal trauma, and traumatic brain injury, as well as assessment of different types of trauma systems and workforces. We also have a focus on improving rates of organ donor registration, particularly among Hispanic Americans.
With the expansion in research identifying optimal practices for improved organ donation outcomes, there is a growing need for a comprehensive and widely acceptable method for measuring hospital organ donation performance. To meet this need, our team is developing a multi-dimensional, truly comprehensive scoring system to assess the organ donation performance of hospitals around the United States.
PI: Ali Salim, MD
Funding Source: American Society of Transplant Surgeons
Although the number of female surgical trainees are reaching gender parity, support for pregnancy and parenthood in the surgical profession has lagged behind the growth in diversity. Childbearing female surgeons face pregnancy-related stigma, barriers to work reductions during pregnancy despite health concerns, financial penalties and loss of referrals following parental leave, and little support for lactation and childcare. Female surgeons, particularly those with rigorous operative schedules, have health risks including double the miscarriage rate of the general population and a higher odds of major pregnancy complications compared to the partners of their male colleagues. Female surgeons are more likely to postpone having children during training, are more likely to need assisted reproductive technology to have a child, and are more likely to have fewer children than they desire. These challenges lead to increased thoughts of attrition, career regret, and changes in professional trajectory. Our division is currently working to characterize the challenges and risks faced by surgeon mothers; to define the measurable benefits of policies that support maternal-fetal health as they relate to burnout, depression, and professional fulfillment; and to provide advocacy to align organizational values with personal and family priorities.
PI: Erika Rangel, MD
The Brigham and Women’s Hospital Burn Center is one of the leading treatment centers nationwide. Members of our team worked in laboratories where Integra, the artificial skin, was discovered. Research into Integra’s application are continued in our own laboratories. Fire prevention education is having a major impact across the country, leading to a steady decline of burn victims over the past decade. The burn program is continuously working with fire departments and other facilities to promote fire prevention and educational burn courses and lectures. The lectures range from initial burn care and resuscitation to reconstruction. These hands-on courses and lectures cover proper care as a well as prevention methods and can be designed per the communities’ needs.
Co-Investigators: Anupama Mehta, MD and Stephanie Nitzschke, MD
Boston-Harvard Burn Injury Model System
The Boston-Harvard Burn Injury Model System is a collaboration of Spaulding, Brigham and Women’s Hospital, Massachusetts General Hospital, Shriner’s Hospital for Children-Boston, Harvard Medical School, and the Boston University School of Public Health. It is one of the four Burn Model Systems funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and dedicated to improving lives of burn survivors.
Our division is proud to collaborate closely with the Stepping Strong Injury Prevention and Intervention Program (SSIPIP) in research endeavors. Ali Salim, MD, FACS oversees its research on falls prevention, firearm injury prevention and emergency preparedness, trauma patient outcomes, violence prevention, traffic safety, and substance use prevention. The SSIPIP is proud to serve as a shared resource in helping to shape the forward progress of the division’s research mission. In addition, the Injury Prevention and Intervention Program collaborates with a variety of community partners to implement and sustain effective programs to prevent injury within the surrounding communities. These programs currently target pedestrian safety, motor vehicle crashes, and falls in older adults.
WalkBoston Pedestrian Safety Program
In 2020, the Stepping Strong Injury Prevention Program awarded a $25,000 grant to WalkBoston, the only statewide pedestrian advocacy organization in Massachusetts, to implement a training program for Boston’s Level 1 trauma centers injury prevention professionals. With the funds, the WalkBoston Pedestrian Safety Program taught injury prevention professionals the tools to pursue pedestrian safety improvements in their hospital catchment area. As there is no current offering of a pedestrian safety program for trauma centers across the United States, we hope this project will serve as a model and lay the groundwork for national efforts.
Social and Economic Causes of Community Violence
With funding from the Stepping Strong Injury Prevention Program, Sarabeth Spitzer, MD is completing a two-year research fellowship at the Center for Surgery and Public Health. Her research addresses social and economic causes of community violence, with specific focus on the impact of disruptive events.
Mentor: Molly Jarman, PhD, MPH
