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.
BACKGROUND: Undertriage (UT) is central to trauma center quality improvement, yet UT definitions vary, and no data-driven consensus target exists for interfacility benchmarking. We compared facility-level UT rates across four methods and assessed the impact on facility benchmarking. METHODS: This retrospective study included patients aged 18 to 89 from Level I & II trauma centers in the ACS TQP Files (2021–2023). Facility-level UT was calculated using the Cribari Matrix Method (CMM), modified Cribari Matrix Method (mCMM), Standardized Triage Assessment Tool (STAT), and High-Intensity Time-Sensitive (HITS) intervention-based definition representing trauma team actions. Paired facility-level UT rates were compared across methods. To estimate benchmarking impact, we calculated within-facility rank change (higher rank = higher UT) relative to CMM. RESULTS: 2,643,881 patients and 515 facilities were included. Median facility-level UT significantly differed by method: CMM 11% [interquartile range: 9–14], mCMM 60% [50–67], STAT 6% [5–8], and HITS 30% [22–40] (all P <0.001). At individual hospitals, the median range of maximum UT values between methods was 53% [44–60]. The median absolute facility rank change between the CMM method and other tools was 129 [54.5–236.5] for mCMM, 48 [17–90] for STAT, and 142 [62.5–252.5] for HITS. CONCLUSIONS: These UT data highlight a concerning level of variation and uncertainty in the calculation and interpretation of a key trauma center performance metric. Until a UT definition is standardized and data-driven UT target goals established, cross-center benchmarking using UT should be interpreted cautiously and may be better suited for within-center trending. LEVEL OF EVIDENCE: Level III, therapeutic/care management.
BACKGROUND: Older adults experience persistent functional and psychosocial consequences after trauma, but it remains unclear whether commonly used health-related quality of life (HRQoL) instruments adequately measure recovery in this population. This systematic review appraised psychometric evidence and risk of bias for HRQoL instruments used in United States trauma cohorts that included adults aged 65 years or older. METHODS: MEDLINE, EMBASE, and CINAHL were searched from inception through January 28, 2026. Two reviewers independently screened studies and extracted data. Risk of bias was evaluated using an adapted Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment. Studies evaluating an HRQoL instrument as the target measure underwent Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) Risk of Bias assessment for each reported measurement property. Results were rated as sufficient, insufficient, or indeterminate and synthesized by instrument. RESULTS: Of 17,195 records, 19 studies were included. Studies most often examined isolated orthopedic trauma (n=7, 36.8%), spinal cord injury (n=6, 31.6%), other injury populations (n=3, 15.8%), polytrauma or systemic injury (n=2, 10.5%), and burns (n=1, 5.3%). Frequently evaluated domains included physical functioning (n=16), emotional or mental health (n=13), overall life satisfaction (n=13), social functioning (n=11), and physical symptoms (n=10). Although all studies used at least one previously developed patient-reported measure, none explicitly adapted or comprehensively validated an eligible HRQoL instrument for older adult trauma patients. Ten studies evaluated a target HRQoL instrument, contributing 33 COSMIN measurement property assessments: 19 sufficient, 10 indeterminate, and 4 insufficient. Overall risk of bias was low in six studies, moderate in eight, serious in three, and unclear in two. CONCLUSIONS: Existing studies show that HRQoL instruments have been used in trauma cohorts including older adults, but they do not establish validity for older adult trauma patients specifically. Future studies should evaluate promising instruments in cohorts designed around older adults’ recovery priorities and clinical characteristics after trauma. LEVEL OF EVIDENCE: Systematic Review; Level III.
BACKGROUND: Transfused red blood cells (RBCs) actively contribute to post-injury hemostasis due to surface phosphatidylserine (PS) exposure. We hypothesized that storage sensitizes erythrocytes to the PIEZO1-induced, calcium‑dependent, PS externalization through calcium and protein kinase C (PKC) dependent activation of the phospholipid scramblase TMEM16F. METHODS: Five units of type O whole blood were obtained for analysis at days 21 and 42 of storage. RBC PS was quantified by annexin V staining on flow cytometry at increasing extracellular CaCl₂ concentrations (0, 0.5, 1.0, 2.0, and 5.0 mmol/L), with and without the PIEZO1 agonist Yoda1 (0.2 μM), PKC agonist Phorbol 12-myristate 13-acetate (PMA; 6 μM) and antagonist chelerythrine chloride (CC; 10 μM), and the TMEM16 family inhibitor niclosamide (2 μM). RBC aggregometry was assessed by multiplate. Data were analyzed by analysis of variance and mixed-effects modeling. RESULTS: PS exposure increased in a Ca²⁺‑dependent manner in both day 21 and 42 RBCs ( p <0.001). PIEZO1 stimulation enhanced this response to a greater extent in day 42 RBCs, with greater change in PS at 1 mmol/L (2.21% vs. −0.44%, p =0.021), 2 mmol/L (7.36% vs. 0.53%, p <0.001), and 5 mmol/L (12.09% vs. 6.40%, p <0.001) CaCl 2 . Compared with calcium alone, Yoda1 and PMA (+61.3%, p <0.001 for both) produced similar increases in PS externalization, whereas PKC inhibition (−45.6%, p =0.009) and TMEM16F inhibition (−4.6%, p =0.99) negated the PIEZO1 response. Yoda1 agonism preserved RBC aggregability after 42 days of storage (51.2±39.0 vs. 2.0±3.5 area under the curve, p <0.001). CONCLUSION: Storage sensitizes RBCs to PIEZO1-mediated, calcium-dependent, PS externalization through PKC- and TMEM16F-dependent signaling. Given its endogenous mechanosensitive properties, pharmacologic PIEZO1 activation highlights a potential mechanism by which mechanical stress encountered during trauma and transfusion through the injured microcirculation may promote erythrocyte phospholipid membrane remodeling and aggregability, contributing to the procoagulant activity of transfused RBCs.
