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Advancing Trauma Center Injury and Violence Prevention: Public Health and Health Care Working Together

Keitt, Sheree, H., MPH, CHES; Alonso, Julie, BA; McPhillips-Tangum, Carol, MPH; Lezin, Nicole, MPPM; Carr, Margaret, BS

Journal of Public Health Management and Practice: May/June 2018 - Volume 24 - Issue 3 - p 292–295
doi: 10.1097/PHH.0000000000000798
News From NACCHO

National Association of County & City Health Officials, Washington, District of Columbia (Mss Keitt and Carr); Safe States Alliance, Atlanta, Georgia (Ms Alonso), CMT Consulting, LLC, Decatur, Georgia (Ms McPhillips-Tangum); and Cole Communications, Inc, Santa Cruz, California (Ms Lezin).

Correspondence: Sheree H. Keitt, MPH, CHES, National Association of County & City Health Officials, 1201 Eye St NW, Fourth Floor, Washington, DC 20005 (

The authors declare no conflicts of interest.

Both public health and health care strive to reduce disease burden and promote preventive measures but often work in silos.1 While health care has traditionally focused on individual care, public health's role is to improve the health of entire communities.1 , 2 The integration of both sectors can serve as a vehicle for the advancement of population health.1 , 2 In 2012, the Institutes of Medicine released a report, Primary Care and Public Health: Exploring Integration to Improve Population Health, which included findings and recommendations on the importance of the health care and public health collaboration.3 The report suggested a primary care/public health continuum that reduces isolation and encourages integration.3

The National Association of County & City Health Officials (NACCHO) and the Safe States Alliance (Safe States) collaborated on a project to strengthen hospital-based injury and violence (IVP) prevention programs by increasing and advancing the synergy among hospital-based and public health efforts. The project convened key stakeholders and developed a shared vision and standards for model trauma center programs. Before this project, there was no national vision and little guidance on how the prevention efforts of trauma centers and public health agencies should align and collaborate to address community IVP needs, nor were there standards for model trauma center IVP programs, including those that exist for local and state public health IVP programs.

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Development of Standards and Indicators for Model Level I and II Trauma Center Injury and Violence Prevention Programs

NACCHO's mission is to be a leader, partner, catalyst, and voice of local health departments (LHDs). To help improve the public health system at the local level, NACCHO develops comprehensive programming to meet the needs of LHDs. Safe States, with its experience and connections with hospital-based injury prevention programs, was the ideal partner to undertake the research and coordination necessary for the Strengthening Hospital-Based Injury and Violence Prevention Programs project. Safe States has a diverse membership from IVP professionals in local, state, and federal public health agencies, as well as from hospital-based and nonprofit settings. The ultimate goal of this project was to improve alignment and collaboration between trauma center IVP programs and public health efforts.

The first step in the project was to conduct an environmental scan to better understand the trauma center–based IVP landscape and gather the insights needed to identify core components of trauma center–based IVP programs. The environmental scan informed a Web-based survey, National Survey of Trauma Injury Prevention Professionals, which was designed to describe IVP efforts in level I and II trauma centers across the country. The survey sought information on 5 core components: data, evidence-based interventions, partnerships, leadership, and resources. The survey was distributed to approximately 591 contacts and received 361 unique responses (53% response rate). Of the responses, 304 (96%) were from level I or II trauma centers. In addition to the survey, Safe States and NACCHO convened a trauma prevention steering committee to provide guidance and engage in 2 stakeholder roundtables to build consensus and establish the core components and standards and indicators.

The Standards and Indicators for Model Level I and II Trauma Center Injury and Violence Prevention Programs are the first to outline the 5 consensus-based core components of a model IVP program within level I and II trauma centers. Each core component is accompanied by a set of voluntary standards and indicators to guide the design and implementation of a model IVP program. The intention is to offer guidance and ideas to programs at all levels on how their programs could be expanded or strengthened while also providing concrete, consensus-based descriptions of what constitutes a model program. Ideally, a model program would be more likely to deliver the shared goals of public health, which is to reduce the burden and costs of IVP in communities across the United States.

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Five Core Components of the Standards and Indicators

The standards and indicators are organized according to 5 core components that are essential for program success:

  • Leadership: Trauma centers have a leadership role in educating and influencing others about the potential of IVP prevention. These prevention efforts aim to reduce the burden of injury and its costs to health systems and society, as well as its potential to drive positive changes in community health outcomes. This leadership occurs both internally, helping articulate the need for and value of the program's activities and impact within hospital chains of command, and externally in the community.
  • Resources: With adequate resources including staffing, expertise, skills, and funding, programs can fulfill their responsibilities and potential to achieve sustainable IVP prevention outcomes.
  • Data: The ability to collect, access, interpret, use, and present injury and/or violence data is considered a core competency for IVP prevention. Indeed, the role of data is central to overall public health practice. With access to multiple data sources and an ability to interpret data, programs are better able to respond to the main sources of the burden of IVP in each community and reduce the costs incurred by systems and society.
  • Effective interventions: Level I and II trauma centers are required to implement programmatic interventions addressing 1 or more of the significant causes of injury in the community. It is crucial to devote the program's intervention resources wisely and evaluate interventions to understand whether they worked as intended. Also, as programs grow in size and scope, it is appropriate to take on a more complex portfolio of interventions, working as appropriate with partners.
  • Partnerships: IVP prevention activities extend across a wide range of topics, mechanisms of injury, risk and protective factors, behaviors, populations, and social determinants of health. No single organization can be expected to address these alone; partnerships are essential for any trauma center–based IVP program.
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Opportunities and Recommendations for Collaboration

Key findings of the environmental scan and survey presented challenges experienced by hospital trauma centers when working with local or state health departments. An overall understanding of the connection between clinical care and public health was also identified as a challenge. Although IVP programs reported strong relationships with local and state health departments, they were less satisfied with their partnerships with local and state health department partners as compared with other types of external and internal partners. This dissatisfaction may be due to the lack of understanding by hospital trauma centers on how to work with public health because of the differences in approaches to work.

According to the 2016 National Profile of Local Health Departments (Profile Study)—the only comprehensive survey of LHD infrastructure and practice—22% of LHDs are engaged in violence prevention activities and 42% in injury prevention activities.4 Although less than half of LHDs report providing population-based prevention services for IVP prevention, 89% of LHDs report that violence prevention programs and services are provided by another organization in their community.4 Also, the Profile Study states that there has been a decline in LHDs forming partnerships with health care agencies.5 There was a drop, from 57% in 2008 to 35% in 2016, in the proportion of LHDs in partnership with hospitals to share personnel and resources or have formal written agreements.5

There are opportunities for public health to collaborate with hospitals to identify community needs, determine community priorities, and jointly develop and implement a plan to improve population health outcomes.6 LHDs are the backbone of the public health system in the United States and serve on the front lines to strengthen communities. The Public Health Accreditation Board (PHAB) offers voluntary national accreditation for LHDs, which has a goal to advance quality and performance to improve and protect the health of communities served by tribal, state, local, and territorial public health departments.7 PHAB standards for accreditation include several prerequisites that can lead to health care and public health collaboration.8 One prerequisite requires the inclusion of a comprehensive community health assessment (CHA) and data collection, analysis, and dissemination of results.8 Moreover, LHDs are also required to engage and involve their communities to address community-specific health needs.8

Similarly, trauma centers have requirements for registration, certification, and designation, based primarily on their designation as level I to IV centers. Recent changes to these requirements, particularly those specific to IVP, present new opportunities for IVP activities and programs within communities and states. The Patient Protection and Affordable Care Act (ACA) requires that nonprofit hospitals conduct and report on a community health needs assessment (CHNA) every 3 years to maintain their tax-exempt status.6 , 9–11 The CHNA must include a description of the assessment process, including how input was obtained from the community and public health members.9–11 Furthermore, ACA requires that the CHNA take into account input from persons representing the broad interests of the community served by the hospital, including at least 1 state, local, tribal, or regional governmental public health department or a State Office of Rural Health.9–11

Overall, there are several recommendations that hospitals and LHDs can implement to increase collaboration and advance population health in their communities:

  • Collaborating on a joint CHA/CHNA process that fulfills both LHD and hospital requirements;
  • Jointly engaging in community-level, cross-sectoral partnerships, such as local committees or task forces;
  • Sharing relevant local data resources for quantitative and qualitative health and social determinants information in hospital service and LHD's community;
  • LHDs assisting the hospital with data analysis by offering staff time from the epidemiologist or biostatistician;
  • LHDs serving as partner in executing the hospital implementation plans or community health improvement plans that follow a CHNA; and
  • Training of hospital staff or being informally mentored by someone in a local public health department.
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The development of the Standards and Indicators for Model Level I and II Trauma Center Injury and Violence Prevention Programs is designed to support the IVP professional and hospital leadership with tangible ideas for expanding or strengthening programs at all levels, moving beyond minimum requirements. Again, it is the first to provide concrete, consensus-based descriptions of what constitutes a model level I or II trauma center IVP program. The hope is that a model program will have the shared goals of public health.

Ideally, the development of these voluntary, consensus-based components and associated standards and indicators will inform the development of future guidance and requirements set by the American College of Surgeons and others for trauma center IVP programs. Furthermore, the key findings and guidance within this resource present an opportunity to increase alignment and strengthen collaboration between trauma centers and public health.

Engaging LHDs in partnerships with hospitals, specifically trauma centers, is critical to improving IVP efforts at the local level. Having a shared vision can be mutually beneficial in the process of developing a strategy to improve the health outcomes of the community.

The publication Standards and Indicators for Model Level I and II Trauma Center Injury and Violence Prevention Programs is available at

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1. Prybil LD, Scutchfield FD, Dixon RE. The evolution of public health-hospital collaboration in the United. States. Public Health Rep. 2016;131(4):522–525.
2. Pratt R, Gyllstrom B, Gearin K, et al Primary care and public health perspectives on integration at the local level: a multi-state study. J Am Board Fam Med. 2017;30(5):601–607.
3. Institutes of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012. Accessed January 3, 2018.
4. National Association of County & City Health Officials. 2016 NACCHO Profile of Local Health Departments. Published 2017. Accessed January 3, 2018.
5. National Association of County & City Health Officials. NACCHO'S 2016 Profile Study: public health's role in clinical medicine. Published 2017. Accessed January 3, 2018.
6. Beatty KE, Wilson KD, Ciecior A, Stringer L. Collaboration among Missouri nonprofit hospitals and local health departments: content analysis of community health needs assessments. Am J Public Health. 2015;105(S2):S337–S344.
7. Public Health Accreditation Board. What is Public Health Depart-ment Accreditation? Accessed January 3, 2018.
8. Public Health Accreditation Board. Public Health Accreditation Board standards: an overview. Accessed January 3, 2018.
9. Internal Revenue Service. Internal revenue bulletin: 2015-5. Published 2015. Accessed January 3, 2018.
10. Patient Protection and Affordable Care Act of 2010, §9007. Accessed January 3, 2018.
11. National Association of County & City Health Officials. State-ment of policy: community health needs assessment. Published 2016. Accessed January 3, 2018.
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