The role of trauma centers in reducing the burden of injury

Injury remains one of the most significant but preventable burdens on the US healthcare system. The Centers for Disease Control (CDC) estimates the societal cost of injury to the USA exceeds $670 billion.1 The CDC and the US Department of Health and Human Services, Health Resources and Services Administration (HRSA) recognize primary prevention applied within a public health framework as the most effective measure to reduce the burden of injury. Prevention is outlined as a fundamental component of inclusive trauma systems in HRSA’s ‘Model Trauma Care System Plan’.2 Accordingly, the American College of Surgeons Committee on Trauma (ACSCOT) Resources for Optimal Care of the Injured Patient3 requires all trauma centers to have an organized and effective approach for injury prevention managed by someone in a leadership position. An organized approach requires an institutional strategy to guide program development and sustainability. An effective approach requires using a public health strategy for planning, implementing, and evaluating injury prevention initiatives.4–7

The need for public health guidance in trauma center-based injury prevention

Within the context of trauma system planning, HRSA emphasizes the integration of healthcare and public health resources as essential to effective injury prevention.2 The public health approach is a four-step scientific and systematic process that includes: (1) describing the problem through data collection and surveillance; (2) identifying factors that increase or decrease risk of injury; (3) designing, implementing, and evaluating intervention strategies aimed at decreasing risk factors; and (4) ensuring proven strategies are widely disseminated and implemented in communities nationwide.8–10 Although the ACSCOT resource document promotes the use of public health models, it provides little specific guidance to assist trauma centers with developing these approaches. This critical gap becomes even more challenging when we consider that most trauma center personnel in the USA tasked with conducting injury prevention activities have clinical healthcare backgrounds with little or no formal public health education or experience.11 Moreover, unlike trauma program managers and trauma registrars, there is no ACSCOT training requirement for hospital injury and violence prevention professionals (HIVPPs). Despite several national courses and resources developed specifically to assist HIVPPs with obtaining public health-based injury prevention education (table 1), many HIVPPs reported not being provided the opportunity to use these resources.11

Furthermore, many hospital-based injury prevention programs across the country are significantly underfunded, understaffed, and lack the infrastructure to develop or measure population-level reductions in injury.11 In 2017, a survey conducted by the Safe States Alliance and the National Association of County and City Health Officials (NACCHO) revealed consistent deficits in hospital-based injury prevention programs related to staffing, funding, equipment, and training.12 A subsequent survey of HIVPPs in 2019 highlighted organizational barriers to developing effective approaches for injury prevention, again citing lack of the institutional support and insufficient allocation of fiscal and staffing resources.11 The ramifications of low institutional prioritization of injury prevention were perhaps best illustrated during the COVID-19 pandemic when trauma centers across the USA saw an unprecedented increase in violent injuries.13–17 During this time when injury prevention strategies should have been urgently redirected to reducing interpersonal and community violence, a national survey by the American Trauma Society (ATS) assessing the professional and personal impact of the pandemic on ATS members revealed that injury prevention programs were being suspended or scaled back with injury prevention staff being furloughed or reassigned to clinical duties (ATS member survey, distributed electronically via email on May 8, 2020).

Consensus on national standards for trauma center injury prevention programs

The field of hospital-based injury and violence prevention has yet to reach full potential for reducing the burden of injury on US populations. This may be due in part to the absence of clear guidance for trauma centers to develop an organized, institutionally supported, and sustainable, public health approach to injury prevention. To fill this gap, the 2017 document Standards and Indicators for Model Level I and II Trauma Center Injury and Violence Prevention Programs12 (https://www.safestates.org/page/TraumaIVP) was developed as the national consensus-based guidelines for trauma center injury prevention programs. A secondary purpose of the document was to promote better integration of trauma center injury prevention efforts with those of local and state public health departments.12 The project was funded by the CDC and facilitated by Safe States Alliance (www.safestates.org) and NACCHO (www.naccho.org). The year-long process incorporated guidance from an advisory panel of national trauma and public health organizations, findings from key informant interviews, and results from an online 68-item survey of injury prevention professionals at 591 level I and II trauma centers. The advisory panel identified the primary elements for an organized approach to injury prevention outlined in the ACSCOT Resources for Optimal Care of the Injured Patient: 2014,3 crosswalked these elements with the components of a public health approach to injury prevention outlined in three key documents,18–20 then defined five core components essential for trauma centers to develop an effective approach to reduce the burden of injury and violence in local communities (leadership, resources, data, effective interventions, and partnerships).

The Standards and Indicators document provides a rational for each of the five core components along with a model standard for each component that is intended to guide trauma centers in program development (table 2). The document also provides a comprehensive list of indicators for each component and accompanying standard that can be used to identify program strengths and opportunities for growth. For example, indicator L-2 for the core component of Leadership states ‘The IVP program demonstrates how its activities and priorities align with those of the hospital’s strategic plan’12 (p6).

In consideration of size and institutional differences across trauma centers, the indicators are divided into two main categories: those applicable to newer, or smaller hospital injury prevention programs (referred to as core model programs), and those that apply to larger, more established programs (enhanced model programs). It is important to note the Standards and Indicators were not developed for use as mandates but rather outline voluntary actions meant to guide trauma centers in program development and identification of existing hospital efforts that could be integrated into an organized local, state, and/or national injury prevention approach. Such efforts may include hospital initiatives like the Affordable Care Act mandated community health needs assessment for charitable hospital organizations,21 population health initiatives,22 injury and violence prevention research, and established collaborations with local and state public health programs. To date, anecdotal examples of successful application of the Standards and Indicators by trauma centers have included (1) creating an injury prevention program summary for use during ACSCOT verification surveys, (2) identifying critical gaps in administrative support and data analyses, (3) demonstrating program strengths to hospital administration, and (4) planning for professional development of injury prevention personnel.23