Faculty Bibliography

Importance/UNASSIGNED:An important consequence of cannabis legalization is the potential increase in the number of cannabis-impaired drivers on roads, which may result in higher rates of traffic-related injuries and fatalities. To date, limited information about the effects of recreational cannabis laws (RCLs) on traffic fatalities is available. Objective/UNASSIGNED:To estimate the extent to which the implementation of RCLs is associated with traffic fatalities in Colorado and Washington State. Design, Setting, and Participants/UNASSIGNED:This ecological study used a synthetic control approach to examine the association between RCLs and changes in traffic fatalities in Colorado and Washington State in the post-RCL period (2014-2017). Traffic fatalities data were obtained from the Fatality Analysis Reporting System from January 1, 2005, to December 31, 2017. Data from Colorado and Washington State were compared with synthetic controls. Data were analyzed from January 1, 2005, to December 31, 2017. Main Outcome(s) and Measures/UNASSIGNED:The primary outcome was the rate of traffic fatalities. Sensitivity analyses were performed (1) excluding neighboring states, (2) excluding states without medical cannabis laws (MCLs), and (3) using the enactment date of RCLs to define pre-RCL and post-RCL periods instead of the effective date. Results/UNASSIGNED:Implementation of RCLs was associated with increases in traffic fatalities in Colorado but not in Washington State. The difference between Colorado and its synthetic control in the post-RCL period was 1.46 deaths per 1 billion vehicle miles traveled (VMT) per year (an estimated equivalent of 75 excess fatalities per year; probability = 0.047). The difference between Washington State and its synthetic control was 0.08 deaths per 1 billion VMT per year (probability = 0.674). Results were robust in most sensitivity analyses. The difference between Colorado and synthetic Colorado was 1.84 fatalities per 1 billion VMT per year (94 excess deaths per year; probability = 0.055) after excluding neighboring states and 2.16 fatalities per 1 billion VMT per year (111 excess deaths per year; probability = 0.063) after excluding states without MCLs. The effect was smaller when using the enactment date (24 excess deaths per year; probability = 0.116). Conclusions and Relevance/UNASSIGNED:This study found evidence of an increase in traffic fatalities after the implementation of RCLs in Colorado but not in Washington State. Differences in how RCLs were implemented (eg, density of recreational cannabis stores), out-of-state cannabis tourism, and local factors may explain the different results. These findings highlight the importance of RCLs as a factor that may increase traffic fatalities and call for the identification of policies and enforcement strategies that can help prevent unintended consequences of cannabis legalization.

The rapid growth of the coronavirus disease 2019 (COVID-19) pandemic, limited availability of personal protective equipment, and uncertainties regarding transmission modes of the novel severe acute respiratory syndrome coronavirus - 2 (SARS-CoV-2) have heightened concerns for safety of healthcare workers (HCWs). Systematic studies of occupational risks for COVID-19 in the context of community risks are difficult and are only recently starting to be reported. Ongoing quality improvement studies in various locales and within many affected healthcare institutions are needed. We propose a template design for small-scale quality improvement surveys. Such surveys have the potential for rapid implementation and completion, are cost-effective, impose little administrative or workforce burden, can reveal occupational risks while taking into account community risks, and can be easily repeated with short intervals of time between repetitions. We describe a template design and propose a survey instrument that is easily modifiable to fit the particular needs of various healthcare institutions in the hope of beginning a collaborative effort to refine the design and instrument. These methods, along with data management and analytic techniques, can be widely useful and shared globally. Our goal is to facilitate quality improvement surveys aimed at reducing the risk of occupational infection of healthcare workers during the COVID-19 pandemic.

OBJECTIVE:Protected bike lanes separated from the roadway by physical barriers are relatively new in the United States. This study examined the risk of collisions or falls leading to emergency department visits associated with bicycle facilities (e.g., protected bike lanes, conventional bike lanes demarcated by painted lines, sharrows) and other roadway characteristics in three U.S. cities. METHODS:We prospectively recruited 604 patients from emergency departments in Washington, DC; New York City; and Portland, Oregon during 2015-2017 who fell or crashed while cycling. We used a case-crossover design and conditional logistic regression to compare each fall or crash site with a randomly selected control location along the route leading to the incident. We validated the presence of site characteristics described by participants using Google Street View and city GIS inventories of bicycle facilities and other roadway features. RESULTS:Compared with cycling on lanes of major roads without bicycle facilities, the risk of crashing or falling was lower on conventional bike lanes (adjusted OR = 0.53; 95 % CI = 0.33, 0.86) and local roads with (adjusted OR = 0.31; 95 % CI = 0.13, 0.75) or without bicycle facilities or traffic calming (adjusted OR = 0.39; 95 % CI = 0.23, 0.65). Protected bike lanes with heavy separation (tall, continuous barriers or grade and horizontal separation) were associated with lower risk (adjusted OR = 0.10; 95 % CI = 0.01, 0.95), but those with lighter separation (e.g., parked cars, posts, low curb) had similar risk to major roads when one way (adjusted OR = 1.19; 95 % CI = 0.46, 3.10) and higher risk when they were two way (adjusted OR = 11.38; 95 % CI = 1.40, 92.57); this risk increase was primarily driven by one lane in Washington. Risk increased in the presence of streetcar or train tracks relative to their absence (adjusted OR = 26.65; 95 % CI = 3.23, 220.17), on downhill relative to flat grades (adjusted OR = 1.92; 95 % CI = 1.38, 2.66), and when temporary features like construction or parked cars blocked the cyclist's path relative to when they did not (adjusted OR = 2.23; 95 % CI = 1.46, 3.39). CONCLUSIONS:Certain bicycle facilities are safer for cyclists than riding on major roads. Protected bike lanes vary in how well they shield riders from crashes and falls. Heavier separation, less frequent intersections with roads and driveways, and less complexity appear to contribute to reduced risk in protected bike lanes. Future research should systematically examine the characteristics that reduce risk in protected lanes to guide design. Planners should minimize conflict points when choosing where to place protected bike lanes and should implement countermeasures to increase visibility at these locations when they are unavoidable.

BACKGROUND:While mass-casualty incidents (MCIs) may have competing absolute definitions, a universally ac-cepted criterion is one that strains locally available resources. In the fall of 2017, a MCI occurred in New York and Bellevue Hospital received multiple injured patients within minutes; lessons learned included the need for a formal-ized, efficient patient and injury tracking system. Our objective was to create an organized MCI clinical tracking form for civilian trauma centers. METHODS:After the MCI, the notes of the surgeon responsible for directing patient triage were analyzed. A suc-cinct, organized template was created that allows MCI directors to track demographics, injuries, interventions, and other important information for multiple patients in a real-time fashion. This tool was piloted during a subsequent MCI. RESULTS:In late 2018, the hospital received six patients following another MCI. They arrived within a 4-minute window, with 5 patients being critically injured. Two emergent surgeries and angioembolizations were performed. The tool was used by the MCI director to prioritize and expedite care. All physicians agreed that the tool assisted in orga-nizing diagnostic and therapeutic triage. CONCLUSIONS:During MCIs, a streamlined patient tracking template assists with information recall and communica-tion between providers and may allow for expedited care.

BACKGROUND:Osteopenia is common in the elderly, increasing their risk of sustaining cervical fractures after ground level falls (GLFs). We sought to examine the incidence of blunt cerebrovascular injury (BCVI) and subsequent stroke in elderly GLF patients as compared with other higher injury mechanisms. MATERIALS AND METHODS/METHODS:The Trauma Quality Improvement Program database (2011-2016) was used to identify blunt trauma patients with isolated (other body region abbreviated injury scale <3) cervical spine (C1-C7) fractures. Patients were stratified into three groups: nonelderly patients (<65) with all mechanisms of injury, elderly patients (≥65) with GLF, and elderly patients with all other mechanism of injury. Multivariable logistic regression was used to determine predictors for BCVI, stroke, spinal cord injury, and acute kidney injury. RESULTS:Seventeen thousand six hundred twenty-eight patients with cervical spine injuries were identified. BCVI was highest in the <65 group (0.8%) and lowest in elderly patients with GLF (0.3%, P = 0.001). When controlling for other factors, elderly patients with GLF were less likely to sustain BCVI (adjusted odds ratio: 0.46, P = 0.03) but had comparable rates of stroke attributable to BCVI (18.2% versus 6.5%, P = 0.184) and comparable rate of acute kidney injury compared with elderly patients with other mechanism of injury. CONCLUSIONS:In elderly patients with isolated cervical spine fracture after GLF, BCVI occurs less frequently but is associated with a comparable rate of stroke as compared with other mechanisms. Low injury mechanism should not preclude BCVI screening in the presence of cervical spine fractures.

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

BACKGROUND:Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes. METHODS:Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition. RESULTS:19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001). CONCLUSIONS:Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively.

BACKGROUND:We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI). METHODS:The National Trauma Data Bank (2014-2015) was used to identify elderly (age ≥ 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared. RESULTS:3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, p = 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, p = 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, p = 0.01). CONCLUSION/CONCLUSIONS:Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.

BACKGROUND:Assessing aspects of intersections that may affect the risk of pedestrian injury is critical to developing child pedestrian injury prevention strategies, but visiting intersections to inspect them is costly and time-consuming. Several research teams have validated the use of Google Street View to conduct virtual neighborhood audits that remove the need for field teams to conduct in-person audits. METHODS:We developed a 38-item virtual audit instrument to assess intersections for pedestrian injury risk and tested it on intersections within 700 m of 26 schools in New York City using the Computer-assisted Neighborhood Visual Assessment System (CANVAS) with Google Street View imagery. RESULTS:Six trained auditors tested this instrument for inter-rater reliability on 111 randomly selected intersections and for test-retest reliability on 264 other intersections. Inter-rater kappa scores ranged from -0.01 to 0.92, with nearly half falling above 0.41, the conventional threshold for moderate agreement. Test-retest kappa scores were slightly higher than but highly correlated with inter-rater scores (Spearman rho = 0.83). Items that were highly reliable included the presence of a pedestrian signal (K = 0.92), presence of an overhead structure such as an elevated train or a highway (K = 0.81), and intersection complexity (K = 0.76). CONCLUSIONS:Built environment features of intersections relevant to pedestrian safety can be reliably measured using a virtual audit protocol implemented via CANVAS and Google Street View.