Annotated Bib 5:

Hashmi, Z. G., Jarman, M. P., Uribe-Leitz, T., Goralnick, E., Newgard, C. D., Salim, A., ... & Haider,

A. H. (2019). Access delayed is access denied: relationship between access to trauma center care

and pre-hospital death. Journal of the American College of Surgeons, 228(1), 9-20.

This study was a retrospective cohort study that examined the relationship between adult

(> 15 years old) pre-hospital trauma deaths and timely access to Level I/II trauma care (TC). The

goal of the study was to determine the state-level relationship between age-adjusted mortality

rates (AAMR), prehospital deaths, and timely access to trauma care centers in regard to finding

the number of pre-hospital deaths that could have been prevented with more timely access to TC.

The authors hypothesized that states with poor trauma care access would have an increased

number of pre-hospital deaths. In order to test this hypothesis, the authors used data from several

sources, including state-level Multiple Cause of Death (MCD) data, 1999 to 2016, and data from

a previous study by Branas and colleagues surrounding the proportion of a population in a state

with access to timely TC. The authors of the study as the proportion of the population in a state

able to reach a Level I/II TC within 60 minutes via either air or land transportation. They sorted

the variables from the MCD data into pre-hospital and in-hospital deaths from each state and

created a ratio of the two factors (PH:IH death ratio). They then compared the PH: IH death ratio

to the AAMR and categorized all states with a higher than the national average of the two

variables as “high pre-hospital burden states”. Once those states were determined, they compared

them to the determine the proportion of the population with access to a Level I/II TC within 45 to

60 minutes. Furthermore, the authors sought to determine the amount of preventable pre-hospital

deaths nationwide by dividing the country into quartiles depending on the amount of Level I/II
trauma care centers within 60 minutes. Next, the authors used the average PH: IH death ratio

from the best quartile as a reference quartile for the others to predict the amount of preventable

pre-hospital deaths. They did this by calculating the estimated amount of pre-hospital deaths if

all states had the same PH: IH death ratio as the reference quartile and comparing it to the actual

number of pre-hospital deaths in each state. The study included 1,949,375 adult trauma deaths in

all 50 states, and its primary findings were that state with poor access to a TC had a higher

amount PH: IH death ratio (49.3% of deaths were pre-hospital, 41.6% were in-hospital) and,

nationwide, there were around 129,213 potentially preventable pre-hospital deaths from 1999-

2016. Many other conclusions were reached, but to name them all would constitute a several-

page description that could hardly be defined as a summary. The authors concluded that, though

they were unable to propose a definite solution to reducing the amount of pre-hospital deaths,

believed the integration of an all-inclusive trauma data repository to track the outcomes of

trauma care nationwide could be used to give states with poor access to trauma care ways to

improve their outcomes.

The authors of the study include Zain G. Hashmi MBBS (my advisor); Molly P. Jarman,

Ph.D.; Tarcisio Uribe-Leitz MD, MPH; Eric Goralnick MD, MS; Craig D. Newgard MD, MPH;

Ali Salim MD, FACS; Edward Cornwell III MD, FACS; and Adil H. Haider MD, MPH, FACS.

Each author is qualified to discuss pre-hospital and in-hospital deaths, mortality rates, and access

to trauma care systems based upon their extensive credentials. Dr. Hashmi has a Bachelor’s

Degree in Surgery/Medicine (MBBS), Dr. Jarman has a Ph.D., Tarcisio Uribe-Leitz has a Doctor

of Medicine degree and a Master of Public Health degree, Eric Goralnick has a Doctor of

Medicine degree and a Master of Science, Craig D. Newgard has a Doctor of Medicine degree

and a Master of Public Health degree, Ali Salim has a Doctor of Medicine degree and is a
member of the American College of Surgeons along with Edward Cornwell III and Adil H.

Haider, Edward Cornwell has a Doctor of Medicine, and Adil H. Haider has a Doctor of

Medicine degree and a Master of Public Health Degree. This source was published in October of

2018, thereby making it current on the topic of prehospital and in-hospital deaths, nationwide

mortality rates, and access to Level I/II trauma care systems in each state. It is vital that this

information is current; if it were not, the conclusions could be outdated and inaccurate. The

authors were able to evaluate all prevalent sides of the issue and were able to go broad and deep

within the study. For example, they took into account many factors in order to cover every aspect

of the issue of timely access to a trauma center. They used data from several credible and reliable

sources for mortality rates, in-hospital and pre-hospital deaths and prominence of timely access

to trauma centers in each state. They ensured that the MCD data they did not use was mentioned

in the “discussion” portion of the analysis and justified why it was not used. Lastly, the authors

broke down the access to trauma centers from state-level data into rural and urban components,

exhibiting broad and deep research and analysis. Moreover, the information in this source can be

corroborated elsewhere. As an example, the background portion of the analysis states “...between

200,000 and 300,000 trauma deaths in the US are potentially preventable over a 10-year period,

given optimal, high-quality trauma care.” This can be verified by a book from the National

Academy of Sciences, Engineering, and Medicine entitled A National Trauma Care System:

Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After

Injury that provides the same data from the study. The purpose of this article is to inform the

general public, more specifically doctors of medicine and professionals in emergency care, about

the number of lives that could be saved simply by improving the trauma systems in the states

with the highest pre-hospital burden. The study encourages the enforcement of a nationwide
trauma database that can be used to improve trauma systems across the U.S. and reach the goal

of having zero preventable deaths. This audience is appropriate because creating an all-inclusive

trauma data repository to improve trauma systems nationwide would require the cooperation and

the assistance of all of the professionals with expertise in emergency medicine and trauma care.