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Steere M, Mbugua E, Davis RE, Mailu F, Adam MB. Moving beyond audit: driving system learning using a novel mortality classification system in a tertiary training hospital in Kenya. BMJ Open Qual 2023; 12:bmjoq-2022-002096. [PMID: 37019468 PMCID: PMC10083850 DOI: 10.1136/bmjoq-2022-002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/10/2023] [Indexed: 04/07/2023] Open
Abstract
Clinical classification systems have proliferated since the APGAR score was introduced in 1953. Numerical scores and classification systems enable qualitative clinical descriptors to be transformed into categorical data, with both clinical utility and ability to provide a common language for learning. The clarity of classification rubrics embedded in a mortality classification system provides the shared basis for discussion and comparison of results. Mortality audits have been long seen as learning tools, but have tended to be siloed within a department and driven by individual learner need. We suggest that the learning needs of the system are also important. Therefore, the ability to learn from small mistakes and problems, rather than just from serious adverse events, remains facilitated.We describe a mortality classification system developed for use in the low-resource context and how it is 'fit for purpose,' able to drive both individual trainee, departmental and system learning. The utility of this classification system is that it addresses the low-resource context, including relevant factors such as limited prehospital emergency care, delayed presentation, and resource constraints. We describe five categories: (1) anticipated death or complication following terminal illness; (2) expected death or complication given clinical situation, despite taking preventive measures; (3) unexpected death or complication, not reasonably preventable; (4) potentially preventable death or complication: quality or systems issues identified and (5) unexpected death or complication resulting from medical intervention. We document how this classification system has driven learning at the individual trainee level, the departmental level, supported cross learning between departments and is being integrated into a comprehensive system-wide learning tool.
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Affiliation(s)
- Mardi Steere
- Exec GM Medical and Retrieval Services, Royal Flying Doctor Service Central Operations, Adelaide, South Australia, Australia
- Pediatrics, AIC Kijabe Hospital, Kijabe, Kenya
| | - Evelyn Mbugua
- Executive Director, AIC Cure International, Kijabe, Kiambu, Kenya
| | | | - Faith Mailu
- Director Clinical Services, AIC Kijabe Hospital, Kijabe, Kenya
| | - Mary B Adam
- Pediatrics and Community Health, AIC Kijabe Hospital, Kijabe, Kenya
- The Africa Consortium For Quality Improvement Research in Frontline Health Care, Nairobi, Kenya
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A Propensity Score-Matched Comparison of In-Hospital Mortality between Dedicated Regional Trauma Centers and Emergency Medical Centers in the Republic of Korea. Emerg Med Int 2022; 2022:5749993. [PMID: 36438862 PMCID: PMC9683976 DOI: 10.1155/2022/5749993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
Background In the Republic of Korea, a trauma care system was not created until 2012, at which point regional trauma centers (RTCs) were established nationwide. In accordance with the national emergency care system and legislation, regional and local emergency medical centers (EMCs) also treat patients presenting with trauma. The aim of the present study was to assess whether treatment in RTCs is truly associated with better patient outcomes than that in EMCs by means of propensity score-matched comparisons and to identify populations that would benefit from treatment in RTCs. Methods This study analyzed the data of patients with consecutive emergency visits between January 1, 2018, and December 31, 2018, collected in the National Emergency Department Information System registry. Data from RTCs, designated regional EMCs, or local EMCs were included; data from smaller emergency departments were excluded because, in Korea, dedicated RTCs are established only in hospitals with regional or local EMCs. Propensity scores for treatment in RTCs or EMCs were estimated by logistic regression using linear terms. Mortality rates in RTCs and EMCs were compared between the matched samples. Results The in-hospital mortality rates in the matched cases treated in RTCs and EMCs were 1.4% and 1.6%, respectively. The odds ratio for in-hospital mortality in RTCs over EMCs was 0.984 (95% confidence interval: 0.813–1.191). Among the subgroups evaluated, the subgroup of patients with injuries involving the chest or lower limbs showed a significant difference in the in-hospital mortality rate. Conclusion There was no significant difference in the overall severity-adjusted mortality rate between patients treated in RTCs and EMCs. Treatment in an RTC might benefit those with injuries involving the chest or lower limbs.
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Zhang GX, Chen KJ, Zhu HT, Lin AL, Liu ZH, Liu LC, Ji R, Chan FSY, Fan JKM. Preventable Deaths in Multiple Trauma Patients: The Importance of Auditing and Continuous Quality Improvement. World J Surg 2021; 44:1835-1843. [PMID: 32052106 DOI: 10.1007/s00268-020-05423-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management errors during pre-hospital care, triage process and resuscitation have been widely reported as the major source of preventable and potentially preventable deaths in multiple trauma patients. Common tools for defining whether it is a preventable, potentially preventable or non-preventable death include the Advanced Trauma Life Support (ATLS®) clinical guideline, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS). Therefore, these surrogated scores were utilized in reviewing the study's trauma services. METHODS Trauma data were prospectively collected and retrospectively reviewed from January 1, 2018, to December 31, 2018. All cases of trauma death were discussed and audited by the Hospital Trauma Committee on a regular basis. Standardized form was used to document the patient's management flow and details in every case during the meeting, and the final verdict (whether death was preventable or not) was agreed and signed by every member of the team. The reasons for the death of the patients were further classified into severe injuries, inappropriate/delayed examination, inappropriate/delayed treatment, wrong decision, insufficient supervision/guidance or lack of appropriate guidance. RESULTS A total of 1913 trauma patients were admitted during the study period, 82 of whom were identified as major trauma (either ISS > 15 or trauma team was activated). Among the 82 patients with major trauma, eight were trauma-related deaths, one of which was considered a preventable death and the other 7 were considered unpreventable. The decision from the hospital's performance improvement and patient safety program indicates that for every trauma patient, basic life support principles must be followed in the course of primary investigations for bedside trauma series X-ray (chest and pelvis) and FAST scan in the resuscitation room by a person who meets the criteria for trauma team activation recommended by ATLS®. CONCLUSION Mechanisms to rectify errors in the management of multiple trauma patients are essential for improving the quality of trauma care. Regular auditing in the trauma service is one of the most important parts of performance improvement and patient safety program, and it should be well established by every major trauma center in Mainland China. It can enhance the trauma management processes, decision-making skills and practical skills, thereby continuously improving quality and reducing mortality of this group of patients.
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Affiliation(s)
- Gui-Xi Zhang
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ke-Jin Chen
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Hong-Tao Zhu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ai-Ling Lin
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhong-Hui Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Li-Chang Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ren Ji
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Fion Siu Yin Chan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam Road, Hong Kong Special Administrative Region, China
| | - Joe King Man Fan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam Road, Hong Kong Special Administrative Region, China.
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Kool B, Lilley R, Davie G, de Graaf B, Reid P, Branas C, Civil I, Dicker B, Ameratunga SN. Potential survivability of prehospital injury deaths in New Zealand: a cross-sectional study. Inj Prev 2020; 27:injuryprev-2019-043408. [PMID: 32447305 DOI: 10.1136/injuryprev-2019-043408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/20/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Acknowledging a notable gap in available evidence, this study aimed to assess the survivability of prehospital injury deaths in New Zealand. METHODS A cross-sectional review of prehospital injury death postmortems (PM) undertaken during 2009-2012. Deaths without physical injuries (eg, drownings, suffocations, poisonings), where there was an incomplete body, or insufficient information in the PM, were excluded. Documented injuries were scored using the AIS and an ISS derived. Cases were classified as survivable (ISS <25), potentially survivable (ISS 25-49) and non-survivable (ISS >49). RESULTS Of the 1796 cases able to be ISS scored, 11% (n=193) had injuries classified as survivable, 28% (n=501) potentially survivable and 61% (n=1102) non-survivable. There were significant differences in survivability by age (p=0.017) and intent (p<0.0001). No difference in survivability was observed by sex, ethnicity, day of week, seasonality or distance to advanced-level hospital care. 'Non-survivable' injuries occurred more commonly among those with multiple injuries, transport-related injuries and aged 15-29 year. The majority of 'survivable' cases were deceased when found. Among those alive when found, around half had received either emergency medical services (EMS) or bystander care. One in five survivable cases were classified as having delays in receiving care. DISCUSSION In New Zealand, the majority of injured people who die before reaching hospital do so from non-survivable injuries. More than one third have either survivable or potentially survivable injuries, suggesting an increased need for appropriate bystander first aid, timeliness of EMS care and access to advanced-level hospital care.
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Affiliation(s)
- Bridget Kool
- Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rebbecca Lilley
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Gabrielle Davie
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Brandon de Graaf
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Pararangi Reid
- Te Kupenga Hauora Maori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Charles Branas
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Ian Civil
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bridget Dicker
- Paramedicine Department, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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Utecht J, Ball J, Bowman SM, Dodd J, Judkins J, Maxson RT, Nabaweesi R, Pradhan R, Sanddal ND, Winchell RJ, Brochhausen M. Development and Validation of a Controlled Vocabulary: An OWL Representation of Organizational Structures of Trauma Centers and Trauma Systems. Stud Health Technol Inform 2019; 264:403-407. [PMID: 31437954 PMCID: PMC7357954 DOI: 10.3233/shti190252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In trauma care and trauma care research there exists an implementation gap regarding a consistent controlled vocabulary to describe organizational aspects of trauma centers and trauma systems. This paper describes the development and evaluation of a controlled vocabulary for trauma care organizations. We give a detailed description of the involvement of domain experts in the domain analysis workflow and the authoring of definitions and additional term descriptions. Finally, the paper details the evaluation methodology to assess the initial version of the controlled vocabulary. The results of the evaluation show that our development process yields terms most of which find approval from domain experts not involved in the development. In addition, our evaluation tools resulted in valuable domain expert input to optimize the controlled vocabulary.
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Affiliation(s)
- Joseph Utecht
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jane Ball
- American College of Surgeons, Chicago, Illinois, USA
| | - Stephen M Bowman
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jimm Dodd
- American College of Surgeons, Chicago, Illinois, USA
| | - John Judkins
- Department of Biology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert T Maxson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rosemary Nabaweesi
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rohit Pradhan
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Robert J Winchell
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Mathias Brochhausen
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Johannesdottir BK, Johannesdottir U, Jonsson T, Lund SH, Mogensen B, Gudbjartsson T. High Mortality from Major Vascular Trauma in Traffic Accidents: A Population-Based Study. Scand J Surg 2019; 109:328-335. [PMID: 31354052 DOI: 10.1177/1457496919863944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Injuries involving major arteries are an important cause of mortality and morbidity, most often from road traffic accidents. Our aim was to study the outcome of major vascular trauma from traffic accidents in an entire population, including patients who die at the scene and those who reach hospital alive. MATERIALS AND METHODS This was a retrospective analysis of all patients who sustained major vascular trauma in traffic accidents in Iceland from 2000 to 2011. Patient demographics, mechanism, and location of vascular injury and treatment were registered. Injury scores were calculated and overall survival estimated. RESULTS There were 62 individuals (mean age 44 years, 79% males) with 95 major vascular traumas, giving an incidence of 1.69/100,000 inhabitants (95% confidence interval: 1.27-2.21). A total of 33 died at the scene and 8 during transportation to hospital but 21 (34%) reached hospital alive. Most patients who succumbed had thoracic major vascular traumas (76%) or abdominal major vascular traumas (23%). Mean new injury severity score for the 21 admitted patients was 44. A total of 18 were operated with vascular repair, 3 with endovascular stent graft insertion. The mean hospital stay for discharged patients was 34 days. Altogether, 15 of the 62 patients (24%) survived to discharge from hospital, with a 5-year survival of 86% for discharged patients. CONCLUSION Every other patient with major vascular trauma following traffic accidents died at the scene and a further 13% died during transportation to hospital, most of whom sustained major vascular trauma to the thoracic aorta. However, one-third of the patients reached hospital alive and 71% of them survived to discharge, with excellent long-term survival.
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Affiliation(s)
- B K Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - U Johannesdottir
- Department of Anaesthesia and Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - T Jonsson
- Department of Iceland National Blood Bank, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - S H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - B Mogensen
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Emergency Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - T Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Edem IJ, Dare AJ, Byass P, D'Ambruoso L, Kahn K, Leather AJM, Tollman S, Whitaker J, Davies J. External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study. BMJ Open 2019; 9:e027576. [PMID: 31167869 PMCID: PMC6561452 DOI: 10.1136/bmjopen-2018-027576] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies. SETTING Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa. PARTICIPANTS Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals. METHODS A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care. RESULTS Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems. CONCLUSIONS A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.
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Affiliation(s)
- Idara J Edem
- Department of Surgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Anna J Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter Byass
- Umeå Centre for Global Health Research, Umea Universitet, Umeå, Sweden
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lucia D'Ambruoso
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen School of Medicine and Dentistry, Aberdeen, UK
| | - Kathleen Kahn
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Andy J M Leather
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Stephen Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - John Whitaker
- King's Centre for Global Health, King's Health Partners and King's College London, London, UK
| | - Justine Davies
- Centre for Applied Health Research, University of Birmingham, Birmingham, UK
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Beck B, Smith K, Mercier E, Bernard S, Jones C, Meadley B, Clair TS, Jennings PA, Nehme Z, Burke M, Bassed R, Fitzgerald M, Judson R, Teague W, Mitra B, Mathew J, Buck A, Varma D, Gabbe B, Bray J, McLellan S, Ford J, Siedenburg J, Cameron P. Potentially preventable trauma deaths: A retrospective review. Injury 2019; 50:1009-1016. [PMID: 30898389 DOI: 10.1016/j.injury.2019.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 03/04/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reviewing prehospital trauma deaths provides an opportunity to identify system improvements that may reduce trauma mortality. The objective of this study was to identify the number and rate of potentially preventable trauma deaths through expert panel reviews of prehospital and early in-hospital trauma deaths. METHODS We conducted a retrospective review of prehospital and early in-hospital (<24 h) trauma deaths following a traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria (AV) in the state of Victoria, Australia, between 2008 and 2014. Expert panels were used to review cases that had resuscitation attempted by paramedics and underwent a full autopsy. Patients with a mechanism of hanging, drowning or those with anatomical injuries deemed to be unsurvivable were excluded. RESULTS Of the 1183 cases that underwent full autopsies, resuscitation was attempted by paramedics in 336 (28%) cases. Of these, 113 cases (34%) were deemed to have potentially survivable injuries and underwent expert panel review. There were 90 (80%) deaths that were not preventable, 19 (17%) potentially preventable deaths and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 20% of those cases that underwent review and 7% of cases that had attempted resuscitation. CONCLUSIONS The number of potentially preventable or preventable trauma deaths in the pre-hospital and early in-hospital resuscitation phase was low. Specific circumstances were identified in which the trauma system could be further improved.
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Affiliation(s)
- Ben Beck
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Faculty of Medicine, Laval University, Quebec City, Quebec, Canada.
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia
| | - Eric Mercier
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Victoria, Australia; The Intensive Care Unit, The Alfred Hospital
| | | | - Ben Meadley
- Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia; Ambulance Victoria, Victoria, Australia
| | - Toby St Clair
- Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia; Ambulance Victoria, Victoria, Australia
| | - Paul A Jennings
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia; Ambulance Victoria, Victoria, Australia; Emergency and Trauma Centre, The Alfred, Victoria, Australia
| | - Ziad Nehme
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Centre for Research and Evaluation, Ambulance Victoria, Victoria, Australia; Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia; Ambulance Victoria, Victoria, Australia
| | - Michael Burke
- Victorian Institute of Forensic Medicine, Victoria, Australia
| | - Richard Bassed
- Victorian Institute of Forensic Medicine, Victoria, Australia; Department of Forensic Medicine, Monash University, Victoria, Australia
| | - Mark Fitzgerald
- Trauma Service, The Alfred, Victoria, Australia; National Trauma Research Institute, Victoria, Australia
| | - Rodney Judson
- General Surgery, The Royal Melbourne Hospital, Victoria, Australia; Department of Surgery, The University of Melbourne, Victoria, Australia
| | - Warwick Teague
- Trauma Service, The Royal Children's Hospital, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Surgical Research Group, Murdoch Children's Research Institute, Victoria, Australia
| | - Biswadev Mitra
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; National Trauma Research Institute, Victoria, Australia; Emergency and Trauma Centre, The Alfred, Victoria, Australia
| | - Joseph Mathew
- Trauma Service, The Alfred, Victoria, Australia; National Trauma Research Institute, Victoria, Australia; Emergency and Trauma Centre, The Alfred, Victoria, Australia
| | - Andrew Buck
- Emergency Department, Royal Darwin Hospital, Northern Territory, Australia
| | - Dinesh Varma
- Department of Surgery, The University of Melbourne, Victoria, Australia; Radiology, The Alfred, Victoria, Australia
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Health Data Research UK, Swansea University Medical School, Swansea University, UK
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - Susan McLellan
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Jane Ford
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Josine Siedenburg
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; National Trauma Research Institute, Victoria, Australia; Emergency and Trauma Centre, The Alfred, Victoria, Australia
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Abstract
INTRODUCTION Regionalised trauma systems have been shown to improve outcomes for trauma patients. However, the evaluation of these trauma systems has been oriented towards in-hospital care. Therefore, the epidemiology and care delivered to the injured patients who died in the prehospital setting remain poorly studied. This study aims to provide an overview of a methodological approach to reviewing trauma deaths in order to assess the preventability, identify areas for improvements in the system of care provided to these patients and evaluate the potential for novel interventions to improve outcomes for seriously injured trauma patients. METHODS AND ANALYSIS The planned study is a retrospective review of prehospital and early in-hospital (<24 hours) deaths following traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria between 2008 and 2014. Eligible patients will be identified from the Victorian Ambulance Cardiac Arrest Registry and linked with the National Coronial Information System. For patients who were transported to hospital, data will be linked the Victoria State Trauma Registry. The project will be undertaken in four phases: (1) survivability assessment; (2) preventability assessment; (3) identification of potential areas for improvement; and (4) identification of potentially useful novel technologies. Survivability assessment will be based on predetermined anatomical injuries considered unsurvivable. For patients with potentially survivable injuries, multidisciplinary expert panel reviews will be conducted to assess the preventability as well as the identification of potential areas for improvement and the utility of novel technologies. ETHICS AND DISSEMINATION The present study was approved by the Victorian Department of Justice and Regulation HREC (CF/16/272) and the Monash University HREC (CF16/532 - 2016000259). Results of the study will be published in peer-reviewed journals and reports provided to Ambulance Victoria, the Victorian State Trauma Committee and the Victorian State Government Department of Health and Human Services.
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Affiliation(s)
- Eric Mercier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Peter A Cameron
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Center for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
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Oliver GJ, Walter DP, Redmond AD. Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades. Injury 2017; 48:978-984. [PMID: 28363752 DOI: 10.1016/j.injury.2017.01.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/26/2016] [Accepted: 01/20/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVES In 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes. METHODS We examined the full Coroner's inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull's probits to match the original protocol. RESULTS One hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%. CONCLUSIONS The number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.
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Affiliation(s)
- G J Oliver
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK.
| | - D P Walter
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
| | - A D Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester, M15 6JA, UK
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Oliver GJ, Walter DP, Redmond AD. Prehospital deaths from trauma: Are injuries survivable and do bystanders help? Injury 2017; 48:985-991. [PMID: 28262281 DOI: 10.1016/j.injury.2017.02.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 02/14/2017] [Accepted: 02/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Deaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. METHODS We examined the Coroners' inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. RESULTS One hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25-50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or "within minutes" in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. CONCLUSIONS A high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.
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Affiliation(s)
- G J Oliver
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester M15 6JA, UK.
| | - D P Walter
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester M15 6JA, UK
| | - A D Redmond
- Humanitarian and Conflict Response Institute, Ellen Wilkinson Building, Oxford Road, University of Manchester, Manchester M15 6JA, UK
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Bakke HK, Wisborg T. We need to include bystander first aid in trauma research. Scand J Trauma Resusc Emerg Med 2017; 25:32. [PMID: 28335785 PMCID: PMC5364713 DOI: 10.1186/s13049-017-0372-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/27/2017] [Indexed: 12/02/2022] Open
Abstract
Background The chain of trauma survival is a concept that originated in the area of out-of-hospital cardiac arrest (OHCA) and was adapted to the treatment of trauma. In out-of-hospital cardiac arrest research into bystander first aid has resulted in improved outcome. Whereas, in trauma research the first link of the chain of survival is almost ignored. Methods In OHCA, cardiopulmonary resuscitation (CPR) from bystanders has been subject of a vast amount of research, as well as measures and programs to raise the rate of bystander CPR to cardiac arrest victims. These efforts have resulted in improved survival. The research effort has been well grounded in the research community, as demonstrated by its natural inclusion in the uniform reporting template (Utstein) for the treatment of OHCA. In trauma the bystander may contribute by providing an open airway, staunch bleedings, or prevent hypothermia. In trauma however, while the chain of survival has been adopted along with it distinct links, including bystander first aid, the consensus-based uniform reporting template for trauma (the Utstein template) does not include the bystander first aid efforts. There is extremely little research on what first aid measures bystanders provide to trauma victims, and on what impact such measures have on outcome. An important step to improve research on bystander first aid in trauma would be to include this as part of the uniform reporting template for trauma Conclusion The lack of research on bystander first aid makes the first link in the trauma chain of survival the weakest link. We, the trauma research community, should either improve our research and knowledge in this area, or remove the link from the chain of survival
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Affiliation(s)
- Håkon Kvåle Bakke
- Mo i Rana Hospital, Helgeland Hospital Trust, Mo i Rana, Norway. .,Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, IKM, University of Tromsø, Tromsø, Norway. .,Department of Anaesthesiology and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
| | - Torben Wisborg
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, IKM, University of Tromsø, Tromsø, Norway.,Department of Anaesthesiology and Intensive Care, Hammerfest Hospital, Finnmark Health Trust, Hammerfest, Norway.,Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Park JM. Outcomes of the support services for the establishment of regional level 1 trauma centers. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2016. [DOI: 10.5124/jkma.2016.59.12.923] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jong-Min Park
- National Trauma System Management Office, National Emergency Medical Center, National Medical Center, Seoul, Korea
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