Deaths following withdrawal of life-sustaining therapy: Opportunities for quality improvement?

A multidimensional approach to identifying high-performing trauma centers across the United States

INTRODUCTION

The differentiators of centers performing at the highest level of quality and patient safety are likely both structural and cultural. We aimed to combine five indicators representing established domains of trauma quality and to identify and describe the structural characteristics of consistently performing centers.

METHODS

Using American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2020, we evaluated five quality measures across several care domains for adult patients in levels I and II trauma centers: (1) time to operating room for patients with abdominal gunshot wounds and shock, (2) proportion of patients receiving timely venous thromboembolism prophylaxis, (3) failure to rescue (death following a complication), (4) major hospital complications, and (5) mortality. Overall performance was summarized as a composite score incorporating all measures. Centers were ranked from highest to lowest performer. Principal component analysis showed the influence of each indicator on overall performance and supported the composite score approach.

RESULTS

We identified 272 levels I and II centers, with 28 and 27 centers in the top and bottom 10%, respectively. Patients treated in high-performing centers had significant lower rates of death major complications and failure to rescue, compared with low-performing centers ( p < 0.001). The median time to operating room for gunshot wound was almost half that in high compared with low-performing centers, and rates of timely venous thromboembolism prophylaxis were over twofold greater ( p < 0.001). Top performing centers were more likely to be level I centers and cared for a higher number of severely injured patients per annum. Each indicator contributed meaningfully to the variation in scores and centers tended to perform consistently across most indicators.

CONCLUSION

The combination of multiple indicators across dimensions of quality sets a higher standard for performance evaluation and allows the discrimination of centers based on structural elements, specifically level 1 status, and trauma center volume.

LEVEL OF EVIDENCE

Therapeutic /Care Management; Level IV.

Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients

INTRODUCTION

Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST.

METHODS

The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients.

RESULTS

Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h.

CONCLUSIONS

More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.

Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system

BACKGROUND

Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System.

METHODS

An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions.

RESULTS

Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm.

CONCLUSION

Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level V.