Methodology to reliably measure preventable trauma death rate

Trauma-related preventable death; data analysis and panel review at a level 1 trauma centre in Amsterdam, the Netherlands

PURPOSE

Trauma-related death is used as a parameter to evaluate the quality of trauma care and identify cases in which mortality could have been prevented under optimal trauma care conditions. The aim of this study was to identify trauma-related preventable death (TRPD) within our institute by an external expert panel and to evaluate inter-panel reliability.

METHODS

Trauma-related deaths between the 1st of January 2020 and the 1st of February 2022 at the Amsterdam University Medical Centre were identified. The severely injured patients (injury severity score ≥ 16) were enrolled for preventability analysis by an external multidisciplinary panel, consisting of a trauma surgeon, anaesthesiologist, emergency physician, neurosurgeon, and forensic physician. Case descriptions were provided, and panellists were asked to classify deaths as non-preventable, potentially preventable, and preventable. Agreements between the five observers were assessed by Fleiss kappa statistics.

RESULTS

In total 95 trauma-related deaths were identified. Of which 36 fatalities were included for analysis, the mean age was 55.3 years (± 24.5), 69.4% were male and 88.9% suffered blunt trauma. The mean injury severity score was 35.3 (± 15.3). Interobserver agreement within the external panel was moderate for survivability (Fleiss kappa 0.474) but low for categorical preventable death classification (Fleiss kappa 0.298). Most of the disagreements were between non-preventable or potentially preventable with care that could have been improved.

CONCLUSION

Multidisciplinary panel review has a moderate inter-observer agreement regarding survivability and low agreement regarding categorical preventable death classification. A valid definition and classification of TRPD is required to improve inter-observer agreement and quality of trauma care.

Prolyl hydroxylase domain inhibitor is an effective pre-hospital pharmaceutical intervention for trauma and hemorrhagic shock

Pre-hospital potentially preventable trauma related deaths are mainly due to hypoperfusion-induced tissue hypoxia leading to irreversible organ dysfunction at or near the point of injury or during transportation prior to receiving definitive therapy. The prolyl hydroxylase domain (PHD) is an oxygen sensor that regulates tissue adaptation to hypoxia by stabilizing hypoxia inducible factor (HIF). The benefit of PHD inhibitors (PHDi) in the treatment of anemia and lactatemia arises from HIF stabilization, which stimulates endogenous production of erythropoietin and activates lactate recycling through gluconeogenesis. The results of this study provide insight into the therapeutic roles of MK-8617, a pan-inhibitor of PHD-1, 2, and 3, in the mitigation of lactatemia in anesthetized rats with polytrauma and hemorrhagic shock. Additionally, in an anesthetized rat model of lethal decompensated hemorrhagic shock, acute administration of MK-8617 significantly improves one-hour survival and maintains survival at least until 4 h following limited resuscitation with whole blood (20% EBV) at one hour after hemorrhage. This study suggests that pharmaceutical interventions to inhibit prolyl hydroxylase activity can be used as a potential pre-hospital countermeasure for trauma and hemorrhage at or near the point of injury.

The Impact of Protective Devices Across the Spectrum of Trauma Care and Across Racial Groupings

INTRODUCTION

Protective devices such as seat belts and helmets save lives. Most studies only address one aspect of the injury profile - compliance or mortality - not the entire spectrum of trauma care, and little attention is paid to racial differences in the use or impact of protective devices.

METHODS

Patients with blunt mechanisms where using protective devices would be expected were included and were divided into utilizing (P) vs not utilizing protection (Non-P). Chart review included demographics, injuries sustained, hemodynamics, and blood alcohol level. Outcomes included need for emergent operation, complications and death.

RESULTS

Non-P patients were more likely male, presented at night and intoxicated. Highest risk behavior (intoxicated Non-P) presented at night (25.7% of nighttime presentations), and rarely during daytime (6.7% daytime presentations). Non-P were more likely hypotensive and sustain a traumatic brain injury. No race related differences were noted among young patients. Among older (>/=50 years) patients, White patients were least likely Non-P and least likely presented at night. Non-P required more emergent operative intervention, ICU admission, and longer hospital stay. Overall, Non-P was associated with increased risk of death (OR = 1.6 (95% CI = 1.28 - 2.11).

CONCLUSION

Given unique age and racial differences, we advocate for culturally and age specific public service campaigns.

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study

BACKGROUND

Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures.

METHODS

Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications.

RESULTS

93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism.

CONCLUSIONS

REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.

Understanding Regional Trauma Centers and managing a trauma care system in South Korea: a systematic review

The Korean government initiated a plan to designate and establish Regional Trauma Centers to reduce the preventable trauma death rate to <20% so as to be on par with advanced countries by 2020. This initiative was undertaken because the reported preventable trauma death rate was close to 40% in South Korea from 1997 to 2009. This review aimed to provide an overview of these Regional Trauma Centers and discuss further development of the trauma care system to assess its performance. As of September 2021, 15 Regional Trauma Centers had been established through a metropolitan-based designation process. Each center has been equipped with Level-I facilities. These Regional Trauma Centers have had 2 positive effects; namely, an increase in the number of severely injured patients attending these centers and a decrease in the national preventable trauma death rate from 30.5% in 2015 to 19.9% in 2017. The establishment of Regional Trauma Centers can lead to improved performance, maximal efficiency, and reduction of preventable deaths in trauma patients. They can also play a key role in prehospital triage and transportation in the trauma care system.

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

When falls become fatal-Clinical care sequence

OBJECTIVES

This study encompassed fall-related deaths, including those who died prior to medical care, that were admitted to multiple healthcare institutions, regardless of whether they died at home, in long-term care, or in hospice. The common element was that all deaths resulted directly or indirectly from injuries sustained during a fall, regardless of the temporal relationship. This comprehensive approach provides an unusual illustration of the clinical sequence of fall-related deaths. Understanding this pathway lays the groundwork for identification of gaps in healthcare needs.

DESIGN

This is a retrospective study of 2014 fall-related deaths recorded by one medical examiner's office (n = 511) within a larger dataset of all trauma related deaths (n = 1848). Decedent demographic characteristics and fall-related variables associated with the deaths were coded and described.

RESULTS

Of those falling, 483 (94.5%) were from heights less than 10 feet and 394 (77.1%) were aged 65+. The largest proportion of deaths (n = 267, 52.3%) occurred post-discharge from an acute care setting. Of those who had a documented prior fall, 216 (42.3%) had a history of one fall while 31 (6.1%) had ≥2 falls prior to their fatal incident. For the 267 post-acute care deaths, 440 healthcare admissions were involved in their care. Of 267 deaths occurring post-acute care, 129 (48.3%) were readmitted within 30 days. Preventability, defined as opportunities for improvement in care that may have influenced the outcome, was assessed. Of the 1848 trauma deaths, 511 (27.7%) were due to falls of which 361 (70.6%) were determined to be preventable or potentially preventable.

CONCLUSION

Our data show that readmissions and repeated falls are frequent events in the clinical sequence of fall fatalities. Efforts to prevent fall-related readmissions should be a top priority for improving fall outcomes and increasing the quality of life among those at risk of falling.

Bleeding to death in a big city: An analysis of all trauma deaths from hemorrhage in a metropolitan area during 1 year

BACKGROUND

Hemorrhage is the most common cause of potentially preventable trauma deaths, but no studies have focused on all civilian traumatic deaths from hemorrhage, so we describe a year of these deaths from a large county to identify opportunities for preventing hemorrhagic deaths.

METHODS

All trauma-related deaths in Harris County, Texas, in 2014 underwent examination by the medical examiner; patients were excluded if hemorrhage was not their primary reason for death. Deaths were then categorized as preventable/potentially preventable hemorrhage (PPH) or nonpreventable hemorrhage. These categories were compared across mechanism of injury, death location, and anatomic locations of hemorrhage to determine significant differences.

RESULTS

A total of 1,848 deaths were reviewed, and 305 were from uncontrolled hemorrhage. One hundred thirty-seven (44.9%) of these deaths were PPH. Of these PPH, 49 (35.8%) occurred prehospital and an additional 28 (20.4%) died within 1 hour of arriving at an acute care setting. Of the 83 PPH who arrived at a hospital, 21 (25.3%) died at a center not designated as level 1. Isolated truncal bleeding was the source of hemorrhage in 102 (74.5%) of the PPH. Of those who died with truncal PPH, the distribution was 22 chest (21.6%), 39 chest and abdomen (38.2%), 16 abdomen (15.7%), and 25 all other combinations (24.5%). When patients who died within 1 hour of arrival to a hospital were combined with the 168 deaths that occurred prehospital, 223 (74.3%) of 300 deaths occurred before spending 1 hour in a hospital and 77 (34.5%) of 223 of these deaths were PPH.

CONCLUSION

In a well-developed, urban trauma system, 34.5% of patients died from PPH in the prehospital setting or within an hour of hospitalization. Earlier, more effective prehospital resuscitation and truncal hemorrhage control strategies are needed to decrease deaths from PPH.

LEVEL OF EVIDENCE

Therapeutic/Care management, level IV.

Characteristics of Trauma Mortality in Patients with Aortic Injury in Harris County, Texas

BACKGROUND

The National Academies of Science have issued a call for zero preventable trauma deaths. The mortality characteristics in all patients with aortic injury are not well described.

METHODS

All prehospital and hospital medical examiner records for deaths occurring in Harris County, Texas in 2014 were retrospectively reviewed, and patients with traumatic aortic injury were selected. The level of aortic injury was categorized by zone (0 through 9) and further grouped by aortic region (arch, zones 0 to 2; descending thoracic, zones 3 to 5; visceral abdominal, zones 6 to 8; infrarenal, zone 9). Multiple investigators used standardized criteria to categorize deaths as preventable, potentially preventable, or non-preventable.

RESULTS

Of 1848 trauma deaths, 192 (10%) had aortic injury. There were 59 (31%) aortic arch, 144 (75%) descending thoracic, 19 (10%) visceral abdominal, and 20 (10%) infrarenal aortic injuries. There were 178 (93%) non-preventable deaths and 14 (7%) potentially preventable deaths, and none were preventable. Non-preventable deaths were associated with blunt trauma (69%) and the arch or thoracic aorta (93%), whereas potentially preventable deaths were associated with penetrating trauma (93%) and the visceral abdominal or infrarenal aorta (79%) (all p < 0.05). Half of potentially preventable deaths (n = 7) occurred at the scene, and half occurred at a trauma center.

CONCLUSION

Potentially preventable deaths after aortic injury were associated with penetrating mechanism and injury to the visceral abdominal and/or infrarenal aorta. Optimal prehospital and ED treatment include temporizing hemorrhage control, hemostatic resuscitation, and faster transport to definitive treatment.

Establishing a regional pediatric trauma preventable/potentially preventable death rate

PURPOSE

Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma.

METHODS

This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time.

RESULTS

There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients.

CONCLUSION

Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist.

Thoracic damage control surgery

Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24-48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.