THE IMPACT OF MEDICAID EXPANSION ON TRAUMA-RELATED EMERGENCY DEPARTMENT UTILIZATION: A NATIONAL EVALUATION OF POLICY IMPLICATIONS Background The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption. Methods We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%). Results Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p<0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p<0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p<0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p<0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p<0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p<0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p<0.001). Conclusion Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems. Level of evidence Epidemiologic, level III Corresponding author: Lisa Marie Knowlton, M.D., M.P.H., F.R.C.S.C. Assistant Professor of Surgery, Section of Trauma, Surgical Critical Care and Acute Care Surgery Stanford University, 300 Pasteur Drive, H3634 Stanford, CA 94305, Tel 650-725-1097 There are no conflicts of interest to report for any of the authors. Disclosure of Funding: Dr. Knowlton is currently receiving a grant from the American College of Surgeons (the C. James Carrico Faculty Research Fellowship for the Study of Trauma and Critical Care) until 2020. This manuscript will be presented as a podium oral presentation at the 78th Annual Meeting of the American Association for the Surgery of Trauma; September 18-21, 2019 in Dallas, TX. © 2019 Lippincott Williams & Wilkins, Inc.

PREHOSPITAL PLASMA IN INJURED PATIENTS IS ASSOCIATED WITH SURVIVAL PRINCIPALLY IN BLUNT INJURY: RESULTS FROM TWO RANDOMIZED PREHOSPITAL PLASMA TRIALS Introduction Recent evidence demonstrated that prehospital plasma in patients at risk of hemorrhagic shock was safe for ground transport and resulted in a 28-day survival benefit for air medical transport patients. Whether any beneficial effect of prehospital plasma varies across injury mechanism remains unknown. Methods We performed a secondary analysis using a harmonized dataset derived from two recent prehospital plasma randomized trials. Identical inclusion/exclusion criteria and primary/secondary outcomes were employed for the trials. Prehospital time, arrival shock parameters and 24-hour transfusion requirements were compared across plasma and control groups stratified by mechanism of injury. Stratified survival analysis and Cox hazard regression were performed to determine the independent survival benefits of plasma across blunt and penetrating injury. Results Blunt patients had higher injury severity, were older and had a lower GCS. Arrival indices of shock and coagulation parameters were similar across blunt and penetrating injury. The percentage of patients with a prehospital time less than 20 mins was significantly higher for penetrating patients relative to blunt injured patients (28.0% vs 11.6%, p<0.01). Stratified Kaplan-Meier curves demonstrated a significant separation for blunt injured patients (n=465, p=0.01) with no separation demonstrated for penetrating injured patients (n=161, p=0.60) Stratified Cox hazard regression verified, after controlling for all important confounders, that prehospital plasma was associated with a 32% lower independent hazard for 28 day mortality in blunt injured patients (HR 0.68, 95% CI 0.47-0.96, p= 0.03) with no independent survival benefit found in penetrating patients (HR 1.16, 95%CI 0.4-3.1, p=0.78). Conclusion A survival benefit associated with prehospital plasma at 24 hours and 28 days exists primarily in blunt injured patients with no benefit shown in penetrating trauma patients. No detrimental effects attributable to plasma are demonstrated in penetrating injury. These results have important relevance to military and civilian trauma systems. Original Article Secondary Analysis Level of Evidence I Presented as an oral presentation at the 78th annual meeting of the American Association For the Surgery of Trauma & Clinical Congress of Acute Care Surgery, Sept 18-21, 2019, Dallas, TX Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Corresponding Author: Jason L. Sperry MD, MPH, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, Pennsylvania 15213, office 412-802 8270, fax 412-647-1448, sperryjl@upmc.edu Funding: This work was supported by the US Department of Defense (USAMRAA, W81XWH-12-2-0028) and (USAMRAA, W81XWH-12-2-0023) © 2019 Lippincott Williams & Wilkins, Inc.

THE IMPACT OF INTERHOSPITAL TRANSFER ON MORTALITY BENCHMARKING AT LEVEL III AND IV TRAUMA CENTERS: A STEP TOWARDS SHARED MORTALITY ATTRIBUTION IN A STATEWIDE SYSTEM Introduction Many injured patients presenting to level III/IV trauma centers will be transferred to level I/II centers, but how these transfers influence benchmarking at level III/IV centers has not been described. We hypothesized that the apparent observed to expected (O:E) mortality ratios at level III/IV centers are influenced by the location at which mortality is measured in transferred patients. Methods We conducted a retrospective study of adult patients presenting to Level III/IV trauma centers in Pennsylvania from 2008-2017. We used probabilistic matching to match patients transferred between centers. We used a risk-adjusted mortality model to estimate predicted mortality, which we compared to observed mortality at discharge from the level III/IV center (O1) or observed mortality at discharge from the level III/IV center for non-transferred patients and at discharge from the level I/II center for transferred patients (O2). Results In total, 9,477 patients presented to 11 Level III/IV trauma centers over the study period (90% white, 49% female, 97% blunt mechanism, median ISS 8 IQR (4-10). Of these, 4,238 (44%) were transferred to Level I/II centers, of which 3,586 (85%) were able to be matched. Expected mortality in the overall cohort was 332 (3.8%). A total of 332 (3.8%) patients died, of which 177 (53%) died at the initial level III/IV centers (O1). Including post-transfer mortality for transferred patients in addition to observed mortality in non-transferred patients (O2) resulted in worse apparent O:E ratios for all centers and significant differences in O:E ratios for the overall cohort (O1:E: 0.53, 95% CI 0.45-0.61 vs. O2:E: 1.00, 95% CI 0.92-1.11, p<0.001). Conclusions Apparent O:E mortality ratios at level III/IV centers are influenced by the timing of measurement. To provide fair and accurate benchmarking and identify opportunities across the continuum of the trauma system, a system of shared attribution for outcomes of transferred patients should be devised. Study type Level 3: Retrospective cohort study Corresponding author and requests for reprint requests: Daniel Holena, MD MSCE, Department of Surgery, University of Pennsylvania School of Medicine, 51 N 39th St, MOB building 1st floor, Philadelphia PA 19104, Phone: 215-662-7323, holenad@upenn.edu Conflicts of Interest and Source of Funding: No authors have conflicts to declare. Portions of this work were supported by a training grant through the National Heart, Lung, and Blood Institute. (DNH; K08HL131995) Meetings at which this work will be presented: 78th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery in Dallas, Texas Article Type: Clinical Science © 2019 Lippincott Williams & Wilkins, Inc.

Lifting the Burden: State Medicaid Expansion Reduces Financial Risk for the Injured Background Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain due to high out-of-pocket healthcare costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington state—which extended coverage to >600,000 WA residents—was associated with a reduction in financial risk among trauma patients. Methods We analyzed all trauma patients ages 18-64y admitted to the sole Level 1 trauma center in WA from 2012-17. We defined 2012-2013 as the pre-policy period and 2014-2017 as the post-policy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate post-subsistence income and out-of-pocket expenses for our sample; and then applied these two estimates to determine catastrophic healthcare expenditure (CHE) risk as defined by the WHO (out-of-pocket health expenses >40% of estimated household post-subsistence income). Results 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0% and the uninsured rate decreased from 19.2% to 3.7% (p<0.001 for both). There was no significant change in private insurance coverage. ME was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and <0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p<0.01). Conclusions State Medicaid expansion led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers. Level of Evidence Economic analysis, level II. Corresponding Author: John W. Scott, MD MPH, Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104-2499. 617-943-7211, jscott21@uw.edu Meetings: This work will be presented as a podium presentation at the 78th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 18-21, 2019, Dallas, TX Relevant Conflicts of Interest and Funding: None declared © 2019 Lippincott Williams & Wilkins, Inc.

Alcohol-Related Trauma Reinjury Prevention with Hospital-Based Screening in Adult Populations: an Eastern Association for the Surgery of Trauma Evidence-Based Systematic Review Background Unaddressed alcohol use among injured patients may result in recurrent injury or death. Many trauma centers incorporate alcohol screening, brief intervention, and referral to treatment for injured patients with alcohol use disorders, but systematic reviews evaluating the impact of these interventions are lacking. Methods An evidence-based systematic review was performed to answer the following population, intervention, comparator, outcomes (PICO) question: Among adult patients presenting for acute injury, should emergency department (ED), trauma center, or hospital-based alcohol screening with brief intervention and/or referral to treatment be instituted compared with usual care to prevent or decrease reinjury, hospital readmission, alcohol-related offenses, and/or alcohol consumption? A librarian-initiated query of PubMed, MEDLINE, and the Cochrane Library was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of the evidence and create recommendations. The study was registered with PROSPERO (Registration number CRD42019122333). Results Eleven studies met criteria for inclusion, with a total of 1,897 patients who underwent hospital-based alcohol screening, brief intervention, and/or referral to treatment for appropriate patients. There was a relative paucity of data, and studies varied considerably in terms of design, interventions, and outcomes of interest. Overall evidence was assessed as low quality, but a large effect size of intervention was present. Conclusions In adult trauma patients, we conditionally recommend ED, trauma center, or hospital-based alcohol screening with brief intervention and referral to treatment for appropriate patients in order to reduce alcohol-related reinjury. Type of Study Systematic review Level of Evidence Level III evidence Corresponding Author: Lisa M. Kodadek, M.D., Vanderbilt University Medical Center, 1211 21st Ave South Suite 404, Medical Arts Building, Nashville, TN 37212, Tel 619.885.7580, Fax 615.322.0689, E-mail lisa.kodadek@vumc.org, lkodadek@gmail.com Conflict of Interest: No industry or pharmaceutical support was received for this work. The authors report no financial conflicts of interest pertaining to this work. Meeting: This manuscript was presented as a podium presentation during the Guidelines Plenary Session at the Thirty-Second Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 18, 2019 in Austin, Texas. Disclosure of Funding: No funding was obtained for this systematic review. © 2019 Lippincott Williams & Wilkins, Inc.

Factors associated with organ donation by trauma patients in Nova Scotia Background Trauma patients represent a significant pool of potential organ donors (PODs), and previous research suggests that this population is underutilized for organ donation (OD). Our objective was to assess factors associated with OD in the trauma population. Methods We retrospectively analyzed OD in Nova Scotia over a 7-year period (2009-2016) using data from the Nova Scotia Trauma Registry (NSTR) and Nova Scotia Legacy of Life Donor Registry (LLDR). All trauma patients who died in hospital were included. Multiple logistic regression was used to assess factors associated with donation. We also evaluated characteristics, donation types, and reasons for non-donation among trauma PODs. Results There were 689 trauma-related deaths in all hospitals in NS during the study period, of which 39.8% (274/689) met the NSTR definition of a POD. Data on OD was available for 108 of these patients who were referred to the Legacy of Life Program. The conversion rate was 84%. Compared to non-donors, organ donors were significantly younger, had a higher Abbreviated Injury Scale head score and a lower scene Glasgow Coma Scale (GCS) score, were more likely to suffer ischemia from drowning or asphyxia and to require air transport, and were less likely to have comorbidities. Regression analysis showed donation was associated with younger age (OR 0.97, 95% CI 0.95-0.99) and lower GCS score at the scene (OR 0.76, 95% CI 0.66-0.88). Odds of donation were increased with air transport compared to land ambulance (OR 8.27, 95% CI 2.07-33.08) and injury within Halifax Regional Municipality (HRM) compared to injury outside HRM (OR 4.64, 95% CI 1.42-15.10). Among the 60 referred PODs who did not donate, family refusal of consent was the most common reason (28/60; 46.7%). Conclusions Younger age, greater severity of injury, and shorter time to tertiary care were associated with OD in trauma patients. Level of Evidence Level III, Prognostic and Epidemiological. Corresponding author: Robert S. Green, Room 377 Bethune Building, 1276 South Park Street, Halifax, NS, Canada, B3H 2Y9. Phone: (902) 473-7157. Fax: (902) 473-5835. Email: greenrs@dal.ca Presentations at conferences: Annual Meeting of the Trauma Association of Canada, February 22-23, 2018 in Toronto, Ontario. Conflicts of interest: None declared Financial support: Alexandra Hetherington and Sara Lanteigne were supported by a Trustees of the Ross Stewart Smith Studentship from the Research in Medicine Program, Faculty of Medicine, Dalhousie University. Adam Cameron was supported by the Canadian Department of National Defence. Robert Green was supported by a Clinician Scientist Award from the Faculty of Medicine, Dalhousie University. © 2019 Lippincott Williams & Wilkins, Inc.

Memories of Donald Dean Trunkey, MD, FACS No abstract available

Life-Saving Interventions in Pediatric Trauma: A National Trauma Data Bank Experience Background Emergent procedures infrequent in pediatric trauma. We sought determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center. Methods The National Trauma Data Bank (2010 – 2014) was queried for patients age ≤ 19 who underwent LSIs within 1 hour of arrival to the emergency department (ED). LSI included ED thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality. Results Out of 725,284 recorded traumatic encounters, only 1,488 (0.2%) of pediatric patients underwent at least one of the defined LSI during the five-year study period (EDT 1,323; EAP 187). Most patients were ≥ 15 years old (85.6%). Mortality was high but varied by procedure type (EDT 64.3%; EAP 28.3%). Mortality for patients less than 1-year old undergoing EDT was 100%, decreasing to 62.6% in patients aged 15- to 19-years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15 to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately 1 LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center. Conclusion LSIs in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence. Level of Evidence III – Retrospective cohort study Address correspondence to: Michael L. Nance, MD, Department of Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104. Telephone: 215-590-5932; Email: nance@email.chop.edu. Conflicts of Interest and Sources of Funding: The authors have no conflicts of interest relevant to this article to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Presentations: This research was presented as an oral abstract at the 19th annual Templeton Trauma Symposium on March 1, 2019 in Pittsburgh, PA. © 2019 Lippincott Williams & Wilkins, Inc.

Endothelial cell dysfunction during Anoxia-Reoxygenation is associated with a decrease in ATP levels, rearrangement in lipid bilayer phosphatidylserine asymmetry, and an increase in endothelial cell permeability Background Phosphatidylserine (PS) is normally confined in an energy-dependent manner to the inner leaflet of the lipid cell membrane. During cellular stress PS is exteriorized to the outer layer, initiating a cascade of events. Because cellular stress is often accompanied by decreased energy levels and because maintaining PS asymmetry is an energy-dependent process, it would make sense that cellular stress associated with decreased energy levels is also associated with PS exteriorization that ultimately leads to endothelial cell dysfunction. Our hypothesis was that anoxia-reoxygenation (A-R) is associated with decreased ATP levels, increased PS exteriorization on endothelial cell membranes, and increased endothelial cell membrane permeability. Methods The effect on ATP levels during anoxia-reoxygenation was measured via colorimetric assay in cultured cells. To measure the effect of A-R on PS levels, cultured cells underwent A-R and exteriorized PS levels and also total cell PS were measured via biofluorescence assay. Finally, we measured endothelial cell monolayer permeability to albumin after A-R. Results ATP levels in cell culture decreased 27% from baseline after A-R (p<0.02). There was over a 2-fold increase in exteriorized PS as compared to controls (p<0.01). Interestingly, we found that during A-R, the total amount of cellular PS increased (p<0.01). The finding that total PS changed 2-fold over normal cells suggested that not only is there a change in the distribution of PS across the cell membrane, but there may also be an increase in the amount of PS inside the cell. Finally, A-R increased endothelial cell monolayer permeability (p<0.01). Conclusions We found that endothelial cell dysfunction during A-R is associated with decreased ATP levels, increased PS exteriorization, and increased in monolayer permeability. This supports the idea that phosphatidylserine exteriorization may a key event during clinical scenarios involving oxygen lack and may one day lead to novel therapies in these situations. Level of Evidence Basic Science Paper Correspondence: Gregory Victorino, MD, 1411 E 31st St, Dept of Surgery—UCSF East Bay, QIC 22134, Oakland, CA 94602, T 5104378370, F 5104375127. Gregory.victorino@ucsf.edu There are no conflicts of interest to report. Manuscript presented at the 77th Annual Meeting of the American Association for the Surgery of Trauma, Sep 26-29, 2018 in San Diego, CA Funding support from NIH KO8 GMO81361 © 2019 Lippincott Williams & Wilkins, Inc.

Prehospital Resuscitation In Adult Patients Following Injury: A Western Trauma Association Critical Decisions Algorithm Level of Evidence III Presented at the 49th Annual Western Trauma Association Meeting, Snowmass, CO, March 3-8, 2019 Conflicts of Interest: The authors have no conflicts of interest to declare and have received no financial or material support related to this manuscript Disclaimer: The results and opinions expressed in this article are those of the authors, and do not reflect the opinions or official policy of any of the listed affiliated institutions, the United States Army, or the Department of Defense (if military co-authors). Corresponding Author: Jason L. Sperry MD, MPH, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, Pennsylvania 15213, office 412-802 8270, fax 412-647-1448. sperryjl@upmc.edu © 2019 Lippincott Williams & Wilkins, Inc.