BackgroundEach year in the USA, 1.5–2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries.Methods/designThe trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons’ policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally.DiscussionThe TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons’ regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results.Trial registrationClinicalTrials.gov NCT02655354. Registered 27 July 2015.

Washington State children have unmet needs upon returning to public schools after concussion. The student-centered RTL model and checklist for implementing RTL guidelines can help schools provide timely RTL services following concussion.

Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons' clinical guidelines for U.S. trauma care systems.

Objective Each year in the United States 1.5–2.5 million individuals are so severely injured that they require hospitalization. Multiple psychiatric, substance use, and chronic medical disorders are endemic among injury survivors with and without traumatic brain injury, yet few investigations have assessed the association between the cumulative burden of these conditions and healthcare outcomes. The investigation aimed to assess the associations between comorbid psychiatric disorders, alcohol and drug use disorders, medical disorders, traumatic brain injury, and violent and suicide related index injury hospitalizations, and subsequent post-injury outcomes that included recurrent hospitalization and death. Method Recurrent hospitalization and all-cause mortality were examined in this population-based retrospective cohort study. A total of 76,942 patients hospitalized in Washington State during 2006–2007 were followed for five years. ICD-9-CM codes were used to identify conditions prior to or at the index admission; E-Codes were used to identify firearm, assaultive violence, and suicide/overdose index injury hospitalization mechanisms. Results Adjusted regression analyses demonstrated a significant, “dose-response” relationship between an increasing cumulative burden of disorders and an increasing risk of recurrent hospitalization (≥ 4 conditions, Relative Risk =3.89, 95% Confidence Interval (CI) =3.66–4.14). Adjusted Cox proportional hazard regression demonstrated a similar relationship between increasing cumulative burden of disorders and all-cause mortality (≥ 4 conditions, Hazard Ratio =5.33, 95% CI =4.71–6.04). Conclusions Increasing cumulative burden of disorders was associated with greater post-injury risk of recurrent hospitalization and death. Orchestrated investigative and policy efforts could introduce screening and intervention procedures that target this spectrum of comorbidity.