The San Francisco Injury Center for Research and Prevention (SFIC) was one of the first of the centers of excellence in injury control established nationally with a grant from the Centers for Disease Control (CDC). The Center has been funded continuously by the CDC since 1989, but has also attracted funding from the U.S. military, private and public foundations, industry, and the San Francisco Mayor's Office of Criminal Justice. Since its inception, the SFIC has played an important role in the San Francisco community in the prevention and treatment of traumatic injuries. The daily interaction with a large number of severely injured patients admitted to the Trauma Center at the San Francisco General Medical Center serves as the impetus for SFIC investigators to continually re-evaluate methods of treating injuries and to identify focus areas for injury prevention. Over the years, our broad research agenda has ranged from the investigation of the molecular basis of traumatic brain injury to interventions designed to reduce post-traumatic stress disorder (PTSD) in children who have been injured. Through the collaboration with the SF Department of Public Health, the SFIC has conducted primary prevention research in the areas of pedestrian and violent injuries. The following are a sampling of current areas of investigation.
Each year, approximately 1,300 children ages 5-9 die as the result of unintentional injuries in the United Sates, and at least 1 million sustain non-fatal injuries, with a resulting 50,000 permanent disabilities and a staggering $3 million cost. Sadly, while most of these injuries are preventable, the efforts to prevent pediatric injuries are fragmented, poorly funded and in need of creative innovation. Preliminary data have shown that "serious games" that are both educational and fun are effective in teaching children basic safety skills. The San Francisco Injury Center has been on the forefront of this movement with the development of "Ace's Adventures," an interactive video game designed for early elementary school students that teaches children about traffic safety. The next step in this endeavor is to test the efficacy of this innovative approach to injury control using a simulated "safety street" that can be assembled at various elementary schools in San Francisco.
Mental Health and Injury
Psychiatric disorders are a known risk factor for intentional injuries such as suicide and assault, but the association between these disorders and unintentional injuries has not been well studied. Injury prevention among these patients is particularly important because, as a group, they consume greater resources after injury and are at high risk for failure to return to independent living. Researchers at the SFIC were the first to document that individuals with a psychiatric disorder, when compared to those without mental illness, had twice the rate of unintentional injury requiring hospitalization and 4.5 times the odds of injury recidivism. Current work involves the identification of patients with psychiatric disorders during their acute hospitalization following trauma. This will present an opportunity to intervene in this cycle and can decrease the overall injury rate in this high-risk population.
Interpersonal violent injury is a major public health issue in the United States. Among patients who survive their initial intentional injuries, the rate of re-injury may be as high as 55%. Trauma centers stand at the forefront in the care of major injuries, but to date, health care providers in this setting have done little to address the root causes and risk factors that lead to violent injury. To address this deficit, injury center investigators developed The Wraparound Project which uses culturally competent case management to target those 14-30 year old patients who are admitted for violent injury. Of those enrolled thus far the re-injury rate is down from 35% historically to 3%. Expansion of these efforts could have a major impact on the current epidemic of violent injury.
San Francisco has been identified as one of the worst cities for pedestrians in the country. Pedestrian injuries account for 49% of all traffic-related fatalities in this city, compared to a national average of 13%. Over 700 pedestrians require care at our trauma center each year and at least 20 die. Investigators from the SFIC were instrumental in developing the linkages necessary for a more complete picture of local pedestrian issues, by linking data from ambulances, hospital records, the police and the coroner's office. The surveillance tool developed for our study allowed us to identify areas of our city and county where pedestrians were most likely to be injured and over the past few years, several safety measures have been installed at these intersections, including pedestrian countdown signals, flashing beacons, and radar speed display signs. We have begun to compile the cost estimates for each pedestrian injury in San Francisco. The SFIC is perfectly positioned to become the first city in the nation to describe the true cost of pedestrian injuries and to critically evaluate the cost-effectiveness of pedestrian safety measures.
Once admitted to the hospital, patients at the San Francisco General Medical Center are offered the opportunity to enroll in a number of pioneering research projects. These projects are focused on various aspects of resuscitation after injury, from early identification of occult shock using ultrasound and near-infrared technology in the emergency department, to the use of tissue oxygen monitors to guide resuscitation in the surgical intensive care unit. Investigators at the SFIC developed the first national data base of patients who have received the hemostatic drug activated factors VII (rFVIIa) after severe trauma and this database will contain the largest accumulation of such data in the world. Researchers at the SFIC are recognized nationally and internationally for their pioneering work on the prevention of clotting disorders after traumatic injuries including the use of new prophylactic agents and for the development of prophylactic guidelines for use in both civilian and military trauma centers. We are currently working with several other trauma centers to establish a practice guideline for the use of blood and blood products after severe injury.
One of the goals of the SFIC is to train the next generation of surgeons in the area of injury prevention and control. To that end, we incorporate premedical students who work as research assistants in preparation for medical school. We work closely with the department of pediatrics in helping to focus their prevention efforts. We have trained nine NIH-sponsored post-doctorate research fellows to date, who have identified trauma/critical care as their area of interest in surgery. Investigators in our center have developed the first simulation center in San Francisco for the training of anesthesiologists and surgeons using computer-controlled mannequins and simulated scenarios. We have developed a unique trauma curriculum with imbedded simulation and have demonstrated that these important patient-safety initiatives translate into improved performance in real-life situations such as during a trauma code in our emergency department. We are in the process of validating these initial findings and are anticipating expanding our simulation courses to prepare teams of nurses and physicians to deal with injuries likely to be encountered during a disaster, such as a major earthquake or a terrorist event. We have been involved in teaching and implementation of ultrasound as a modality in a hospital in Kampala, Uganda.