Molly Price Jarman

BACKGROUND: State emergency medical services (EMS) and trauma systems determine prehospital triage, transport, trauma center designation, data reporting, and quality improvement, yet their contemporary organization has not been systematically characterized. We sought to describe state-level EMS and trauma system structures, policies, resources, and perceived gaps across the United States. METHODS: We conducted a cross-sectional survey of EMS and trauma system leaders in all 50 states and the District of Columbia from July 2025 through March 2026. A 56-item instrument utilizing categorical, Likert-type, rank-order, and free-text items assessed oversight, prehospital triage and transport, clinical protocols, trauma center verification, registries, quality improvement, and funding. Respondents were recruited by email and phone. Multiple respondents could contribute complementary domain-level information to a single state profile. Responses were summarized descriptively. RESULTS: All 51 jurisdictions participated. Most states reported a state EMS medical director (84%), statewide trauma triage protocols (84%), and mandatory participation in their state trauma registry (88%). However, operational coordination varied: only 29% had a centralized trauma communications center, only 6% of states reported a single point of contact for helicopter EMS dispatch, and 35% required a certificate of need for new helicopter services. Trauma center verification relied on American College of Surgeons (ACS) verification in 59% of states, while others used state-administered processes. More than half of states rated EMS financial resources in the two lowest adequacy categories, and 55% reported that their trauma system required at least moderate improvement. Rural populations were most frequently identified as underserved (96%) and as experiencing worse outcomes (92%). CONCLUSIONS: State EMS and trauma systems share broad adoption of national clinical standards but differ substantially in governance, coordination, verification, data integration, and funding. LEVEL OF EVIDENCE AND STUDY TYPE: Level V, Prognostic/epidemiological.

Introduction: To support the development of the National Trauma Research Repository (NTRR), a multidisciplinary workgroup used a consensus-driven approach to review established epidemiologic data elements and recommend basic common data elements (CDEs) for inclusion in the NTRR data dictionary. Methods: A 10-member workgroup of military and civilian trauma researchers and data scientists located and reviewed databases, codebooks, data collection forms, and published articles for data elements relevant to trauma epidemiology. Identified data elements were reviewed in a three-round Delphi survey, and monthly meetings with the workgroup were conducted. Consensus during the Delphi survey was analyzed with an 80% agreement threshold. Results: 13 sources were reviewed for epidemiology data elements. After the three survey rounds and workgroup discussions, 33 elements (80%) reached consensus for inclusion, 3 elements (7%) were excluded, and 5 elements (12%) did not reach consensus. Discussion: The Delphi process proved effective in achieving expert consensus on basic CDEs for trauma epidemiologic research. The resulting standardized basic CDEs will improve data harmonization and support consistent data collection in the NTRR. These CDEs represent an initial framework and serve as a foundational starting point for epidemiological data collection within the NTRR. As researchers use the NTRR, the list of CDEs will grow and evolve with the needs of the trauma research community. CDE standardization not only supports interoperable research but also enhances research quality, efficiency, and translation into clinical practice. Level of Evidence: Level VII

Introduction: The COVID-19 pandemic strained the U.S. healthcare system due to significant requirements for inpatient and intensive care unit resources for COVID-19 patients. We examined the association between hospital occupancy and incidence of complications during the COVID-19 pandemic in the Military Health System. Materials and Methods: This retrospective cross-sectional study used inpatient hospital encounters data (October 2019-May 2023) from the U.S. Military Health System Data Repository. TRICARE beneficiaries admitted and treated for traumatic injury, emergency general surgery conditions, myocardial infarction, or cerebrovascular accident at a military treatment facility. We used multivariable logistic regression to determine if the incidence of complications (i.e., catheter-acquired urinary tract infections, central line acquired bloodstream infections, decubitus ulcers, deep vein thrombosis, pulmonary embolism) was associated with changes in hospital occupancy rate (i.e., inpatient days per bed-day per month). Results: Of 24,926 TRICARE beneficiaries eligible for inclusion, 58% were male, 55% White, and 84% non-Hispanic. The average hospital occupancy rate was 0.45 inpatient days per bed-day per month (SD = 0.24) for included hospitals from October 2019 to May 2023. Compared to the lowest hospital occupancy tertile, the likelihood of complications was 36% higher at hospitals in the middle tertile (OR: 1.36, 95% CI, 1.15-1.61), and 20% at hospitals in the higher tertile (OR: 1.20, 95% CI, 1.01-1.43). Conclusions: The incidence of inpatient complications appeared to increase with increasing hospital occupancy. Future disaster preparedness efforts should proactively address widespread workforce shortages to mitigate the effects of hospital occupancy surges.

Background: Trauma centers are implementing geriatric‐focused processes of care, including geriatric consult services, to improve outcomes for injured older adults. We hypothesized that trauma centers with a geriatric consult service would have more geriatric‐focused processes of care and improved hospital‐level mortality for injured older adults. Methods: We surveyed US trauma centers regarding compliance with geriatric‐focused processes of care, including presence of geriatric consult service, palliative care consult service, geriatric pharmacists, screening for frailty, screening for potentially inappropriate home medications, and anticoagulation reversal protocols. Using Trauma Quality Improvement Program data, we calculated hospital‐level observed‐to‐expected (O:E) mortality for patients aged ≥ 65 years treated at surveyed trauma centers, controlling for patient demographics, comorbidities, and injury severity. High‐mortality hospitals were defined as those in the highest quartile of O:E ratio for mortality. Multivariable logistic regression was performed to assess the association of geriatric consult service availability with high‐mortality hospitals while controlling for other hospital‐level characteristics, including trauma verification level, number of beds, geriatric trauma volume, teaching status, and compliance with other geriatric‐focused processes of care. Results: Geriatric consult services were available at 49 of the 145 included trauma centers (34%). Hospitals with geriatric consult services were more likely to have Level I verification (61% vs. 12%, p < 0.001), standardized processes for assessing frailty (43% vs. 15%, p < 0.001), and geriatric pharmacists (55% vs. 33%, p = 0.012). On unadjusted analysis, hospitals with a geriatric consult service were less likely to have higher‐than‐expected mortality (17% vs. 44%, p = 0.009). On multivariable logistic regression, the presence of a geriatric consult service was associated with decreased odds of higher‐than‐expected mortality (OR 0.20, 95% CI 0.05–0.73, p = 0.015). Conclusions: Trauma centers with geriatric consult services have improved hospital‐level mortality for injured older adults and have more processes in place to manage these patients. Additional trauma centers should consider implementing a geriatric consult service.

Background: The closest level I trauma center to an injured patient may be in a different state. Because patients treated at out-of-state trauma centers may face barriers to accessing post-discharge care, we hypothesized that patients treated at out-of-state trauma centers have longer length of stay (LOS) than patients treated at in-state trauma centers. Study Design: Using the HCUP State Inpatient Databases for 13 US states, we included adult patients with a primary injury diagnosis who were treated at a level I trauma center. We performed mixed effects negative binomial regression to assess for differences in LOS between patients treated at in-state vs. out-of-state trauma centers, controlling for the fixed effects of patient demographics, insurance, injury severity and mechanism, medical comorbidities, and discharge venue, as well as the random effect of trauma center state. Results: We identified 107,098 patients, including 6,950 (6.5%) treated at an out-of-state level I trauma center. Unadjusted LOS was 1.3 days longer in out-of-state patients (8.0 vs. 6.7, P<0.001). After adjusting for potential confounders, out-of-state patients had 0.78 day longer LOS than in-state patients (95% CI 0.69-0.87 days). This effect was greater among the subgroup of patients with Medicaid insurance (1.27 days longer, 95% CI 0.99-1.54 days) and those discharged to rehab (1.61 days longer, 95% CI 1.36-1.86 days). Conclusions: Injured patients treated at out-of-state trauma centers have longer LOS than patients treated at in-state trauma centers. Challenges with discharging patients to rehab and limited out-of-state insurance coverage among patients with Medicaid may drive this difference. Repatriation of patients from out-of-state level I trauma centers to in-state hospitals after completion of the acute phase of care may be an approach to addressing prolonged LOS among out-of-state trauma patients.

Background Fall prevention interventions delivered by specially trained emergency medical services (EMS) clinicians in the homes of patients at high risk for falls have been shown to prevent recurrent falls. However, the cost of implementing this ‘community EMS’ approach to fall prevention is a barrier to widespread adoption. The objective of this study was to assess whether a community EMS fall prevention intervention results in overall cost savings for the healthcare system. Methods We performed a cost-effectiveness analysis using a decision-tree model of possible outcomes after an index fall in a simulated population of community-dwelling adults aged ≥65 over a 1-year time horizon. Transition probabilities and costs were obtained through literature review. The intervention, delivered in patients’ homes by specialised EMS clinicians, consisted of environmental modifications, fall prevention education, referral to occupational and physical therapy, and coordination with the patient’s primary care physician. We compared the mean healthcare expenditures per patient among those receiving and not receiving the fall prevention intervention. Results The intervention would result in a net cost savings of $964 per patient compared with no intervention, with an incremental cost-effectiveness ratio of −$22 174 per fall prevented (lower cost and more effective). Holding other variables constant, the programme would remain cost-saving if the effectiveness decreased to a 26% reduction in falls or the programme cost increased to $1634 per patient. Conclusions In this economic modelling analysis, a multifactorial fall prevention intervention delivered by community EMS was cost saving to the healthcare system. Healthcare payors should provide financial support and reimbursement for these programmes.