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Mabry CD, Davis B, Sutherland M, Robertson R, Carger J, Wyrick D, Collins T, Porter A, Kalkwarf K. Progressive Reduction in Preventable Mortality in a State Trauma System Using Continuous Preventable Mortality Review to Drive Provider Education: Results of Analyzing 1,979 Trauma Deaths from 2015 to 2022. J Am Coll Surg 2024; 238:426-434. [PMID: 38149781 DOI: 10.1097/xcs.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND The state legislature codified and funded the Arkansas Trauma System (ATS) in 2009. Quarterly preventable mortality reviews (PMRs) by the ATS began in 2015 and were used to guide state-wide targeted education to reduce preventable or potentially preventable (P/PP) deaths. We present the results of this PMR-education initiative from 2015 to 2022. STUDY DESIGN The ATS uses a statistical sampling model of the Arkansas Trauma Registry to select ~40% of the deaths for quarterly review, reflecting the overall the Arkansas Trauma Registry mortality population. A multispecialty PMR committee reviews the medical records from prehospital care to death, and hospital and regional advisory council reviews for each death. The PMR committee assigns opportunities for improvement (OFIs), cause(s) of death, and the likelihood of preventability for each case. Education to improve trauma care includes annual state-wide trauma meetings, novel classes targeted at level III/IV trauma center hospital providers, trauma evidence-based guidelines, and PMR "pearls." RESULTS We reviewed 1,979 deaths with 211 (10.6%) deaths judged to be P/PP deaths. There was a progressive decrease in P/PP deaths and OFIs for P/PP deaths. Five OFI types targeted by education accounted for 72% of the 24 possible OFI types in the P/PP cases, and 94% of the "contributory OFIs." Reductions in "delay in treatment" resulted in the most rapid decrease in P/PP deaths. CONCLUSIONS Using ongoing PMR studies to target provider education led to a reduction in P/PP deaths and OFIs for P/PP deaths. Focusing on education designed to improve preventable mortality can result in a substantial decrease in P/PP deaths by 43% (14% to 8%) for trauma systems.
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Affiliation(s)
- Charles D Mabry
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Benjamin Davis
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michael Sutherland
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (Sutherland)
| | - Ronald Robertson
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - Deidre Wyrick
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
- Division of Pediatric Surgery and Section of Pediatric Critical Care Medicine, Department of Surgery, University of Arkansas College of Medicine and Arkansas Children's Hospital, Little Rock, AR (Wyrick)
| | - Terry Collins
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Austin Porter
- Department of Health Policy and Management, Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences and Arkansas Department of Health, Little Rock, AR (Porter)
| | - Kyle Kalkwarf
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
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Hardy BM, Enninghorst N, King KL, Balogh ZJ. The most critically injured polytrauma patient mortality: should it be a measurement of trauma system performance? Eur J Trauma Emerg Surg 2024; 50:115-119. [PMID: 35982325 PMCID: PMC10924014 DOI: 10.1007/s00068-022-02073-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The risk of death after traumatic injury in developed trauma systems is at an all-time low. Among 'major trauma' patients (injury severity score, ISS > 15), the risk of dying is less than 10%. This group contains critical polytrauma patients (ISS 50-75), with high risks of death. We hypothesized that the reduction in trauma mortality was driven by reduction in moderate injury severity and that death from critical polytrauma remained persistently high. METHODS A 20-year retrospective analysis ending December 2021 of a Level-1 trauma center's registry was performed on all trauma patients admitted with ISS > 15. Patients' demographics, injury severity and outcomes were collected. Multivariate logistic regression analysis was performed. Mortality was examined for the entire study group and separately for the subset of critical polytrauma patients (ISS 50-75). RESULTS A total of 8462 severely injured (ISS > 15) trauma patients were identified during the 20-year period. Of these 238 (2.8%) were critical polytrauma patients (ISS 50-75). ISS > 15 mortality decreased from 11.3 to 9.4% over the study period (Adjusted OR 0.98, 0.97-0.99). ISS 50-75 mortality did not change significantly (46.2-60.0%), adjusted OR 0.96, 0.92-1.00). CONCLUSION The improvement in trauma mortality over the past 20 years has not been experienced equally. The ISS50-75 critical polytrauma mortality is a practical group to capture. It could be a group for deeper study and reporting to drive improvement.
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Affiliation(s)
- Benjamin Maurice Hardy
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | | | - Kate Louise King
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt Janos Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia.
- University of Newcastle, Newcastle, NSW, Australia.
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Jacobson N, Miller A, Mackman SA, Bhatnagar A, Aranda J, Chinn M, Otero R. Mortality in the Emergency Department and the Effectiveness of Conventional Safety Event Reporting. Cureus 2023; 15:e45472. [PMID: 37859929 PMCID: PMC10583127 DOI: 10.7759/cureus.45472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/21/2023] Open
Abstract
Background Patient mortality reviews identify care, system, and process deficiencies. Patient deaths undergo quarterly review in our academic emergency department (ED), whereas in other departments, mortality reviews are requested by the pronouncing physician within 24 hours. In the ED, individual physicians encounter barriers to 24-hour reviews, including feasibility, the perception of futility, re-exposure to traumatic events, and a high frequency of pre-hospital and non-preventable deaths. This quality review aimed to determine the preventable death rate, contributing factors to ED patient mortality, cases requiring further review, and the capture rate of individual case submissions into the patient safety reporting system. Methods A retrospective chart review was performed on all patient deaths occurring in our ED from July 2019 to February 2020. All patients 18 years or older who were pronounced dead in the ED during our data collection period were included. Patients declared deceased pre-hospital, on an inpatient floor, or in the operating room were excluded. Deaths were assessed for characteristics such as sex, presence of a pulse upon arrival, diagnostics and interventions performed, and whether the cause of death was traumatic or medical. Deaths were categorized on a 5-point Likert scale ranging from "not preventable" to "likely preventable." The presence or absence of contributing factors and the need for further review were recorded. Results Of the 166 reviewed cases, 87% (n=144) were non-preventable due to a terminal condition upon arrival, 12% (n=20) were non-preventable despite maximal efforts, 0.6% (n=1) were non-preventable despite a medical or systems error, and 0.6% (n=1) were possibly preventable due to a medical or systems error. No cases were definitively preventable. Only 1.2% (n=2) of cases required further safety review. In 55% (n=91) of cases, the patient arrived without a pulse. Medical deaths (60%, n=100) outnumbered traumatic deaths (39%, n=64). The most utilized diagnostic test was ultrasound (67%, n=111), and the most utilized intervention was advanced cardiac life support (59%, n=98). Conclusion There is a high prevalence of unpreventable deaths in the ED (99%, n=164). Only two cases (1.2%) were identified for further patient safety review. Standard safety event reporting practices correctly identified all possibly preventable ED deaths.
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Affiliation(s)
- Nancy Jacobson
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Abigail Miller
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Sean A Mackman
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | - Jamie Aranda
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Matthew Chinn
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Ronny Otero
- Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
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Kwon J, Lee M, Kim Y, Moon J, Huh Y, Song S, Kim S, Ko JI, Jung K. Trauma system establishment and outcome improvement: a retrospective national cohort study in South Korea. Int J Surg 2023; 109:2293-2302. [PMID: 37204433 PMCID: PMC10442102 DOI: 10.1097/js9.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Trauma is a major cause of mortality, disability, and health care costs worldwide. The establishment of a trauma system is known to solve these problems, but few studies have objectively evaluated the impact of a trauma system on outcomes. Since 2012, South Korea has established a national trauma system based on the implementation of 17 regional trauma centers nationwide and the improvement of the prehospital transfer system. This study aimed to measure the changes in performance and outcome according to the established national trauma system. MATERIAL AND METHODS In this national cohort-based, retrospective follow-up observational study, the authors calculated the preventable trauma death rate (PTDR) by conducting a multipanel review of patients who died in 2015, 2017, and 2019. Furthermore, the authors constructed a risk-adjusted mortality prediction model of 4 767 876 patients between 2015 and 2019 using the extended-International Classification of Disease Injury Severity Scores to compare outcomes. RESULTS The PTDR was lower in 2019 than in 2015 (15.7 vs. 30.5, P <0.001) and 2017 (15.7 vs. 19.9%, P <0.001) representing 1247 additional lives saved in 2019 compared to that in 2015. In the risk-adjusted model, total trauma mortality was highest in 2015 at 0.56%, followed by that in 2016 and 2017 (0.50%), 2018 (0.51%), and 2019 (0.48%), revealing a significant decrease in mortality over the years ( P <0.001 for trend), representing nearly 800 additional lives saved. The number of deaths for more severe patients with a probability of survival less than 0.25 significantly decreased from 81.50% in 2015 to 66.17% in 2019 ( P <0.001). CONCLUSIONS The authors observed a significant reduction in the PTDR and risk-adjusted trauma mortality in the 5-year follow-up since 2015 when the national trauma system was established. These findings could serve as a model for low-income and middle-income countries, where trauma systems are not yet established.
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Affiliation(s)
- Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
| | - Myeonggyun Lee
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
| | - Seoyoung Song
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
| | - Sora Kim
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
| | - Jung-in Ko
- Department of Emergency Medicine
- National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine
- Ajou University Hospital, Gyeonggi South Regional Trauma Center, Suwon
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Choi DH, Jeong TS, Jang MJ. Comparison of Preventable Trauma Death Rates in Patients With Traumatic Brain Injury Before and After the Establishment of Regional Trauma Center: A Single Center Experience. Korean J Neurotrauma 2023; 19:227-233. [PMID: 37431367 PMCID: PMC10329879 DOI: 10.13004/kjnt.2023.19.e16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 07/12/2023] Open
Abstract
Objective To compare preventable trauma death rates (PTDRs) in patients with traumatic brain injury before and after the establishment of a regional trauma center (RTC) at a single center. Methods Our institution established an RTC in 2014. A total of 709 patients were enrolled from January 2011 to December 2013 (before RTC) and 672 from January 2019 to December 2021 (after RTC). The revised trauma score, injury severity score, and trauma and injury severity score (TRISS) were evaluated. Definitive preventable (DP), possibly preventable (PP), and non-preventable deaths were defined as TRISS >0.5, TRISS 0.25-0.5, and TRISS <0.25, respectively. PTDR was the proportion of deaths from DP+PP out of all deaths, and the preventable major trauma death rate (PMTDR) was the proportion of deaths from DP+PP out of all DP+PP. Results The overall mortality rates before and after the establishment of RTC were 20.3 and 13.1%, respectively. PTDR was lower after the establishment of RTC than before (90.3% vs. 79.5%). The PMTDR was also lower after the establishment of RTC than before (18.8% vs. 9.7%). The ratio of direct hospital visits was higher in patients before the establishment of RTC than in those after (74.9% vs. 61.3%, p<0.001). Conclusion Establishing the RTC reduced PTDRs. Additional studies on factors associated with PTDR reduction are required.
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Affiliation(s)
- Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae Seok Jeong
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Myung Jin Jang
- Regional Trauma Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Zhou Q, Huang H, Zheng L, Chen H, Zeng Y. Effects of the establishment of trauma centres on the mortality rate among seriously injured patients: a propensity score matching retrospective study. BMC Emerg Med 2023; 23:5. [PMID: 36653746 PMCID: PMC9850752 DOI: 10.1186/s12873-023-00776-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Little evidence suggests that trauma centres are associated with a lower risk of mortality in severely injured patients (Injury Severity Score (ISS) ≥16) with multiple injuries in China. The objective of this study was to determine the association between the establishment of trauma centres and mortality among severely injured patients with multiple injuries and to identify some risk factors associated with mortality. METHODS A retrospective single-centre study was performed including trauma patients admitted to the First Affiliated Hospital of Nanchang University (FAHNU) between January 2016 and December 2021. To determine whether the establishment of a trauma centre was an independent predictor of mortality, logistic regression analysis and propensity score matching (PSM) were performed. RESULTS Among 431 trauma patients, 172 were enrolled before the trauma centre was built, while 259 were included after the trauma centre was built. A higher frequency of older age and traffic accident injury was found in patients diagnosed after the trauma centre was built. The times for the completion of CT examinations, emergency operations and blood transfusions in the "after trauma centre" group were shorter than those in the "before trauma centre" group. However, the total expenditure of patients was increased. In the overall group, univariate and multivariate logistic regression analyses showed that a higher ISS was an independent predictor for worse mortality (OR = 17.859, 95% CI, 8.207-38.86, P < 0.001), while the establishment of a trauma centre was favourable for patient survival (OR = 0.492), which was also demonstrated by PSM. After determining the cut-off value of time for the completion of CT examination, emergency operation and blood transfusion, we found that the values were within the "golden one hour", and it was better for patients when the time was less than the cut-off value. CONCLUSION Our study showed that for severely injured patients, the establishment of a trauma centre was favourable for a lower mortality rate. Furthermore, the completion of a CT examination, emergency surgery and blood transfusion in a timely manner and a lower ISS were associated with a decreased mortality rate.
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Affiliation(s)
- Qiangping Zhou
- grid.412604.50000 0004 1758 4073Department of Emergency Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Haijin Huang
- grid.412604.50000 0004 1758 4073Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhui Zheng
- grid.412604.50000 0004 1758 4073Department of Emergency Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Haiming Chen
- grid.412604.50000 0004 1758 4073Department of Emergency Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
| | - Yuanlin Zeng
- grid.412604.50000 0004 1758 4073Department of Emergency Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, 17 Yongwaizheng Street, Nanchang, 330006 Jiangxi China
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Analysis of mortality over 7 years in a mature trauma center: evolution of preventable mortality in severe trauma patients. Eur J Trauma Emerg Surg 2022; 49:1425-1431. [DOI: 10.1007/s00068-022-02194-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
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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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Hong C, Alser O, Gebran A, He Y, Joo W, Kokoroskos N, Velmahos G, Olsen BD, Hammond PT. Modulating Nanoparticle Size to Understand Factors Affecting Hemostatic Efficacy and Maximize Survival in a Lethal Inferior Vena Cava Injury Model. ACS NANO 2022; 16:2494-2510. [PMID: 35090344 PMCID: PMC9989960 DOI: 10.1021/acsnano.1c09108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Intravenous nanoparticle hemostats offer a potentially attractive approach to promote hemostasis, in particular for inaccessible wounds such as noncompressible torso hemorrhage (NCTH). In this work, particle size was tuned over a range of <100-500 nm, and its effect on nanoparticle-platelet interactions was systematically assessed using in vitro and in vivo experiments. Smaller particles bound a larger percentage of platelets per mass of particle delivered, while larger particles resulted in higher particle accumulation on a surface of platelets and collagen. Intermediate particles led to the greatest platelet content in platelet-nanoparticle aggregates, indicating that they may be able to recruit more platelets to the wound. In biodistribution studies, smaller and intermediate nanoparticles exhibited longer circulation lifetimes, while larger nanoparticles resulted in higher pulmonary accumulation. The particles were then challenged in a 2 h lethal inferior vena cava (IVC) puncture model, where intermediate nanoparticles significantly increased both survival and injury-specific targeting relative to saline and unfunctionalized particle controls. An increase in survival in the second hour was likewise observed in the smaller nanoparticles relative to saline controls, though no significant increase in survival was observed in the larger nanoparticle size. In conjunction with prior in vitro and in vivo experiments, these results suggest that platelet content in aggregates and extended nanoparticle circulation lifetimes are instrumental to enhancing hemostasis. Ultimately, this study elucidates the role of particle size in platelet-particle interactions, which can be a useful tool for engineering the performance of particulate hemostats and improving the design of these materials.
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Affiliation(s)
- Celestine Hong
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Osaid Alser
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts 02144, USA
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts 02144, USA
| | - Yanpu He
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Wontae Joo
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts 02144, USA
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts 02144, USA
| | - Bradley D. Olsen
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Paula T. Hammond
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
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Moeng MS, Luvhengo TE. Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines. World J Surg 2022; 46:1006-1014. [PMID: 35119512 DOI: 10.1007/s00268-021-06414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. AIM This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. METHODS We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). RESULTS Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. CONCLUSION Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.
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Affiliation(s)
- M S Moeng
- Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), University of the Witwatersrand, Box 7053, Cresta, Johannesburg, Republic of South Africa.
| | - T E Luvhengo
- Clinical Head Department of Surgery, CMJAH, University of the Witwatersrand, Johannesburg, Republic of South Africa
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Reyes AA, Hurlbert RJ, Dumont TM, Ramey WL. The Number of Organ System Injuries Is a Predictor of Intrahospital Mortality in Complete Cervical Spinal Cord Injury. World Neurosurg 2021; 158:e788-e792. [PMID: 34808411 DOI: 10.1016/j.wneu.2021.11.063] [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: 10/09/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to determine the extent to which polytrauma significantly impacts intrahospital mortality among patients with complete cervical spinal cord injury (cSCI) and to assess whether an organ system-based approach would be appropriate as a mortality predictor as compared with conventional standards to help guide prognosis and management. METHODS We retrospectively reviewed patient medical records and assessed the type of associated trauma at presentation. We then reviewed its correlation with mortality in patients who were admitted at our institution between 2012 and 2021. Types of associated trauma were classified under the following: traumatic brain injury, abdominal injury, thoracic injury, orthopedic injury, craniofacial injury, genitourinary injury, and vascular injury. RESULTS Thirty patients with complete cSCIs were identified. Increased organ system-based polytrauma had a statistically significant increase in intrahospital mortality (P = 0.01). Using the logistic regression model, for each additional gain in organ system-based trauma, patients had a 2.455 odds ratio of mortality (P = 0.03, 95% confidence interval 1.171-6.348). Zero other organ system injuries in the setting of cSCI provided a predictive mortality probability of 6.6%. One organ system-based trauma provided a 14.8% intrahospital mortality probability, 2 traumas provided a 29.9% mortality probability, 3 traumas provided a 51.1% mortality probability, and 4 other organ-system traumas provided a 72.0% mortality probability. The predictive prognostic accuracy of using number of organ system-based trauma to predict mortality probability was quantified at area under the curve = 0.8264 (95% confidence interval 0.6729-0.9799, P = 0.01). CONCLUSIONS Our research shows that an increased number of organ system injuries is associated with greater intrahospital mortality in polytrauma patients with complete cSCI.
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Affiliation(s)
- Angelica Alvarez Reyes
- Department of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - R John Hurlbert
- Department of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Travis M Dumont
- Department of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Wyatt L Ramey
- Department of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA; Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA.
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Motsumi MJ, Ayane G, Kwati M, Panzirah-Mabaka K, Walsh M. Preventable deaths following road traffic collisions in Botswana: A retrospective review. Injury 2021; 52:2665-2671. [PMID: 33888332 DOI: 10.1016/j.injury.2021.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/27/2021] [Accepted: 04/01/2021] [Indexed: 02/02/2023]
Abstract
Road traffic collisions (RTC) are a major cause of mortality and morbidity in Botswana. To our knowledge no research has been conducted in Botswana to investigate preventable deaths that occur as a result of RTCs. The aim of this study is to establish the rate of preventable deaths from RTCs in the greater Gaborone area in Botswana. This was a 5-year retrospective study conducted at the forensic pathology department for the greater Gaborone area, in Botswana. Nine hundred and nine (909) forensic pathology reports were retrieved. Sixty-eight percent (68.2%) of RTC deaths were considered preventable. Head injury in isolation and in combination with other injuries accounted for 87.6% (796/909) of deaths. Haemorrhagic shock was present in 70.2% (638) of all documented injuries. Another documented injury contributing to fatal RTCs was high spinal cord injury. This injury was documented in 13.1% (119/909) of all deaths. We recommend the implementation of a comprehensive trauma system in Botswana to reduce the number of deaths from RTCs.
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Affiliation(s)
- Mpapho Joseph Motsumi
- Department of Surgery, Faculty of Medicine, University of Botswana, P.O. Box 37 Mogoditshane, Botswana.
| | - Gezahen Ayane
- Department of Surgery, Faculty of Medicine, University of Botswana, P.O. Box 37 Mogoditshane, Botswana
| | - Morapedi Kwati
- Department of Surgery, Princess Marina hospital, Botswana
| | | | - Michael Walsh
- Department of Surgery, Bokamoso private hospital, Botswana
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Validation of a Visual-Based Analytics Tool for Outcome Prediction in Polytrauma Patients (WATSON Trauma Pathway Explorer) and Comparison with the Predictive Values of TRISS. J Clin Med 2021; 10:jcm10102115. [PMID: 34068849 PMCID: PMC8153591 DOI: 10.3390/jcm10102115] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction: Big data-based artificial intelligence (AI) has become increasingly important in medicine and may be helpful in the future to predict diseases and outcomes. For severely injured patients, a new analytics tool has recently been developed (WATSON Trauma Pathway Explorer) to assess individual risk profiles early after trauma. We performed a validation of this tool and a comparison with the Trauma and Injury Severity Score (TRISS), an established trauma survival estimation score. Methods: Prospective data collection, level I trauma centre, 1 January 2018–31 December 2019. Inclusion criteria: Primary admission for trauma, injury severity score (ISS) ≥ 16, age ≥ 16. Parameters: Age, ISS, temperature, presence of head injury by the Glasgow Coma Scale (GCS). Outcomes: SIRS and sepsis within 21 days and early death within 72 h after hospitalisation. Statistics: Area under the receiver operating characteristic (ROC) curve for predictive quality, calibration plots for graphical goodness of fit, Brier score for overall performance of WATSON and TRISS. Results: Between 2018 and 2019, 107 patients were included (33 female, 74 male; mean age 48.3 ± 19.7; mean temperature 35.9 ± 1.3; median ISS 30, IQR 23–36). The area under the curve (AUC) is 0.77 (95% CI 0.68–0.85) for SIRS and 0.71 (95% CI 0.58–0.83) for sepsis. WATSON and TRISS showed similar AUCs to predict early death (AUC 0.90, 95% CI 0.79–0.99 vs. AUC 0.88, 95% CI 0.77–0.97; p = 0.75). The goodness of fit of WATSON (X2 = 8.19, Hosmer–Lemeshow p = 0.42) was superior to that of TRISS (X2 = 31.93, Hosmer–Lemeshow p < 0.05), as was the overall performance based on Brier score (0.06 vs. 0.11 points). Discussion: The validation supports previous reports in terms of feasibility of the WATSON Trauma Pathway Explorer and emphasises its relevance to predict SIRS, sepsis, and early death when compared with the TRISS method.
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Chae YJ, Lee J, Park JH, Han DG, Ha E, Yi IK. Late Mortality Prediction of Neutrophil-to-lymphocyte and Platelet Ratio in Patients With Trauma Who Underwent Emergency Surgery: A Retrospective Study. J Surg Res 2021; 267:755-761. [PMID: 33583601 DOI: 10.1016/j.jss.2020.11.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/28/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND We aimed to evaluate the usefulness of neutrophil-to-lymphocyte (N/L) and neutrophil-to-lymphocyte platelet (N/LP) ratios in predicting late mortality of patients with trauma who underwent emergency surgery. MATERIALS AND METHODS We retrospectively evaluated patients with trauma older than 19 y who underwent emergency surgery at our level I trauma center. Blood count-based ratios (N/L and N/LP at days 1, 3, and 7 of hospitalization) and trauma scores were analyzed. Statistical analysis was performed using univariable logistic regression and receiver operating curves. RESULTS A total of 209 patients were evaluated. N/LP at day 7, N/L at day 7, Trauma Injury Severity Score, Revised Trauma Score, and Injury Severity Score were significantly associated with late mortality. Area under the receiver operating characteristic curves for predicting mortality was highest for N/LP at day 7 (0.867 [95% confidence interval 0.798-0.936], P < 0.001). The group with N/LP greater than the cutoff value (9.3, sensitivity 77.3%, specificity 83.1%) at day 7 showed higher mortality than the group with N/LP less than the cutoff value (35.4% versus 3.2%, P < 0.001, respectively) at day 7. CONCLUSIONS N/LP at day 7 may be a superior predictor of late mortality compared with preexisting trauma scores in patients with major trauma undergoing emergency surgery, by better reflecting the systemic inflammation status.
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Affiliation(s)
- Yun Jeong Chae
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Jiyoung Lee
- Department of Anesthesiology and Pain Medicine CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Ji Hyun Park
- Office of Biostatistics, Ajou Research Institute for Innovation Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Do-Gyun Han
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - Eunji Ha
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, South Korea
| | - In Kyong Yi
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, South Korea.
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Trauma research in the Nordic countries, 1995-2018 - a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:20. [PMID: 32164776 PMCID: PMC7069175 DOI: 10.1186/s13049-020-0703-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/15/2020] [Indexed: 11/14/2022] Open
Abstract
Background Trauma is a major cause of mortality and reduced quality of life. Most trauma-related research originates from trauma centres, and there are limited available data regarding the treatment of trauma patients throughout the Nordic countries. These countries differ from economically similar countries due to their cold climate, mix of rural and urban areas, and the long distances separating many residents from a trauma centre. Research funders and the general public expect trauma research to focus on all links in the treatment chain. Here we conducted a systematic review to assess the amount of trauma-related research from the Nordic countries between January 1995 and April 2018, and the distribution of this research among different countries and different parts of the trauma treatment chain. Methods A systematic literature search was conducted in Medline, Embase, the Cochrane Library, Web of Science, and Scopus. We included studies concerning the trauma population from Nordic countries, and published between January 1995 and April 2018. Two independent reviewers screened titles and abstracts, and performed data extraction from full-text articles. Results The literature search yielded 5117 titles and abstracts, of which 844 full-text articles were included in our analysis. During this period, the annual number of publications increased. Publications were equally distributed among Norway, Sweden, and Denmark in terms of numbers; however, Norway had more publications relative to inhabitants. There were fewer overall publications from Finland and Iceland. We identified mostly cohort studies and very few randomized controlled trials. Studies focused on the level of care were predominantly epidemiological studies. Research at the pre-hospital level was three-fold more frequent than research on other elements of the trauma treatment chain. Conclusion The rate of publications in the field of trauma care in the Nordic countries has increased over recent years. However, several parts of the trauma treatment chain are still unexplored and most of the available studies are observational studies with low research evidence.
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Pfeifer R, Halvachizadeh S, Schick S, Sprengel K, Jensen KO, Teuben M, Mica L, Neuhaus V, Pape HC. Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review. World J Surg 2019; 43:2438-2446. [PMID: 31214829 DOI: 10.1007/s00268-019-05056-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes. METHODS Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study. RESULTS After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%). CONCLUSION According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.
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Affiliation(s)
- Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sylvia Schick
- Institute of Legal Medicine, Ludwig-Maximillians-Universität (LMU) Munich, Munich, Germany
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Ladislav Mica
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Valentin Neuhaus
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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17
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Gioffrè-Florio M, Murabito LM, Visalli C, Pergolizzi FP, Famà F. Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. G Chir 2019; 39:35-40. [PMID: 29549679 DOI: 10.11138/gchir/2018.39.1.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population. PATIENTS AND METHOD We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT. RESULTS In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%. DISCUSSION The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity. CONCLUSIONS Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.
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18
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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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20
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Kong T, Park YS, Lee HS, Kim S, Lee JW, You JS, Chung HS, Park I, Chung SP. The delta neutrophil index predicts development of multiple organ dysfunction syndrome and 30-day mortality in trauma patients admitted to an intensive care unit: a retrospective analysis. Sci Rep 2018; 8:17515. [PMID: 30504778 PMCID: PMC6269472 DOI: 10.1038/s41598-018-35796-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/09/2018] [Indexed: 02/08/2023] Open
Abstract
No studies have examined the role of delta neutrophil index (DNI) reflecting on immature granulocytes in determining the severity of multiple organ dysfunction (MODS) and short-term mortality. This study investigated the utility of the automatically calculated DNI as a prognostic marker of severity in trauma patients who were admitted to an intensive care unit (ICU). We retrospectively analysed prospective data of eligible patients. We investigated 366 patients. On multivariable logistic regression analysis, higher DNI values at 12 h (odds ratio [OR], 1.079; 95% confidence interval [CI]: 1.037-1.123; p < 0.001) and 24 h were strong independent predictors of MODS development. Multivariable Cox regression analysis revealed that increased DNI at 12 h (hazard ratio [HR], 1.051; 95% CI, 1.024-1.079; p < 0.001) was a strong independent predictor of short-term mortality. The increased predictability of MODS after trauma was closely associated with a DNI > 3.25% at 12 h (OR, 12.7; 95% CI: 6.12-26.35; p < 0.001). A cut-off of >5.3% at 12 h was significantly associated with an increased risk of 30-day mortality (HR, 18.111; 95% CI, 6.988-46.935; p < 0.001). The DNI is suitable for rapid and simple estimation of the severity of traumatic injury using an automated haematologic analyser without additional cost or time.
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Affiliation(s)
- Taeyoung Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sinae Kim
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Lee
- Department of Laboratory Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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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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Trauma center maturity measured by an analysis of preventable and potentially preventable deaths: there is always something to be learned…. Surg Today 2018; 48:1004-1010. [PMID: 29936602 DOI: 10.1007/s00595-018-1687-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/08/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases. METHODS We analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process. RESULTS During the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors. CONCLUSIONS Although the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.
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Abstract
OBJECTIVE Emergency major abdominal surgery carries a high mortality rate. The aim of this present study was to characterize a population of deceased abdominal surgical patients, to examine how many died unexpectedly and how many were subject to treatment limitations. MATERIALS AND METHODS We included adult emergency abdominal surgical patients who died within 30 days postoperatively. We collected data from January 1, 2013, to December 31, 2014, in a Danish tertiary care hospital (Herlev). RESULTS A total of 138 patients were included which corresponded to a crude mortality rate of 16.5% in the population. Four percent (5 of 138) of the patients died unexpectedly without any prior signs of deterioration and 46% (65 of 138) experienced a complicated treatment course, 67% of which was treated in the intensive care unit (ICU). The remaining 50% (68 of 138) had treatment limitations, applied pre- or postoperatively, of which 4% were treated in the ICU ward. CONCLUSIONS In the present study, we found a high number of patients with treatment limitations, offering one explanation to why so relatively few high-risk surgical patients are admitted to the ICU ward. Whether intermediary wards could serve as a viable alternative for these patients, securing a sufficient level of treatment without taking up scarce beds in the intensive care unit, remains an important question for future studies. Furthermore, five patients died unexpectedly, without any clear cause of death, proving that continual strides toward improving the overall process of postoperative care are still demanded.
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Kong T, Park JE, Park YS, Lee HS, You JS, Chung HS, Park I, Chung SP. Usefulness of serial measurement of the red blood cell distribution width to predict 28-day mortality in patients with trauma. Am J Emerg Med 2017; 35:1819-1827. [DOI: 10.1016/j.ajem.2017.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/02/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022] Open
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Abe T, Nagano T, Ochiai H. Potential benefit of physician-staffed helicopter emergency medical service for regional trauma care system activation: An observational study in rural Japan. J Rural Med 2017; 12:12-19. [PMID: 28593012 PMCID: PMC5458347 DOI: 10.2185/jrm.2919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/31/2016] [Indexed: 11/27/2022] Open
Abstract
Objective: Involvement of all regional medical facilities in a trauma system is challenging in rural regions. We hypothesized that the physician-staffed helicopter emergency medical service potentially encouraged local facilities to participate in trauma systems by providing the transport of patients with trauma to those facilities in a rural setting. Materials and Methods: We performed two retrospective observational studies. First, yearly changes in the numbers of patients with trauma and destination facilities were surveyed using records from the Miyazaki physician-staffed helicopter emergency medical service from April 2012 to March 2014. Second, we obtained data from medical records regarding the mechanism of injury, severity of injury, resuscitative interventions performed within 24 h after admission, secondary transports owing to undertriage by attending physicians, and deaths resulting from potentially preventable causes. Data from patients transported to the designated trauma center and those transported to non-designated trauma centers in Miyazaki were compared. Results: In total, 524 patients were included. The number of patients transported to non-designated trauma centers and the number of non-designated trauma centers receiving patients increased after the second year. We surveyed 469 patient medical records (90%). There were 194 patients with major injuries (41%) and 104 patients with multiple injuries (22%), and 185 patients (39%) received resuscitative interventions. The designated trauma centers received many more patients with trauma (366 vs. 103), including many more patients with major injuries (47% vs. 21%, p < 0.01) and multiple injuries (25% vs. 13%, p < 0.01), than the non-designated trauma centers. The number of patients with major injuries and patients who received resuscitative interventions increased for non-designated trauma centers after the second year. There were 9 secondary transports and 26 deaths. None of these secondary transports resulted from undertriage by staff physicians and none of these deaths resulted from potentially preventable causes. Conclusion: The rural physician-staffed helicopter emergency medical service potentially encouraged non-designated trauma centers to participate in trauma systems while maintaining patient safety.
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Affiliation(s)
- Tomohiro Abe
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
| | - Takehiko Nagano
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
| | - Hidenobu Ochiai
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
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Endo A, Shiraishi A, Matsui H, Hondo K, Otomo Y. Assessment of Progress in Early Trauma Care in Japan over the Past Decade: Achievements and Areas for Future Improvement. J Am Coll Surg 2016; 224:191-198.e5. [PMID: 27825915 DOI: 10.1016/j.jamcollsurg.2016.10.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Strategies to optimize early trauma care have been introduced in Japan; however, detailed evaluation of the progress achieved has not been reported. STUDY DESIGN In this retrospective observational study, patients registered in the Japanese nationwide trauma registry were stratified according to probability of survival (Ps) > 0.5 or ≤ 0.5, respectively. Mortality rates during the first 2 days and in-hospital mortality rates were compared between early (2004 to 2009) and late cohorts (2010 to 2014) in each group, using mixed effects logistic regression analysis. Improvement in mortality rates during the first 2 days among subgroups were also assessed. RESULTS We analyzed 80,949 patients with Ps > 0.5 (early, 25,917; late, 55,032) and 8,898 patients with Ps ≤ 0.5 (early, 3,511; late, 5,387). Mortality rates during the first 2 days in both groups were significantly reduced (adjusted odds ratio [AOR; 95% CI] 0.61 [0.53 to 0.69] in the Ps > 0.5 group and 0.67 [0.60 to 0.76] in the Ps ≤ 0.5 group). In-hospital mortality rates in both groups were also significantly reduced (AOR [95% CI] 0.70 [0.64 to 0.76] and 0.73 [0.64 to 0.82], respectively). Significant improvements were observed in patients with a Revised Trauma Score ≥ 7 on arrival or an Abbreviated Injury Scale (AIS) of the abdomen ≥ 3. Limited improvements were observed in patients with head AIS ≥ 3 and in patients who underwent thoracotomy. CONCLUSIONS Although early trauma care has generally improved, specific progress was variable. Focused panel review of patients with severe head injury or undergoing thoracotomy may be an efficient strategy for further improvement.
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Affiliation(s)
- Akira Endo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan; Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kenichi Hondo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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TLEMISSOV AS, DAULETYAROVA MA, BULEGENOV TA, RAKHYPBEKOV TK, GRJIBOVSKI AM. Epidemiology of Geriatric Trauma in an Urban Kazakhstani Setting. IRANIAN JOURNAL OF PUBLIC HEALTH 2016; 45:1411-1419. [PMID: 28032058 PMCID: PMC5182249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 04/12/2016] [Indexed: 10/26/2022]
Abstract
BACKGROUND External causes of death are still among the main causes of death in the countries of the former Soviet Union. We studied epidemiology of injuries among elderly in a typical Kazakhstani city. METHODS Data on all injuries among individuals aged 60 yr or older in the city of Semey (former Semipalatinsk) from 2010 to 2012 was collected from medical files. We present absolute numbers and incidence rates for the main ICD-codes in Chapters XIX and XX of ICD-10 by gender, ethnic background and place where the injury occurred. RESULTS Altogether, there were 6065 injuries in 2010-2012. The overall incidence of increased from 4746.6 per 100000 in 2010 to 5577.7 per 100000 in 2012. Injuries to the elbow and forearm, injuries to the shoulder and upper arm, and injuries to the knee and lower leg were the most common and comprised 17.3%, 15.5% and 14.6% of all injuries, respectively. Falls constituted 82.2% of all injuries. Most injuries occurred at home and among ethnic Russians. CONCLUSION The incidence and the absolute number of injuries among elderly in Semey increased during the study period in both men and women. Given that the population of Kazakhstan is getting older, injuries are expected to require more attention from the public health professionals and health authorities. More than four-fifths of traumas resulted from falls making this cause of injury the first target for preventive measures.
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Affiliation(s)
| | | | | | | | - Andrej M GRJIBOVSKI
- Dept. of International Public Health, Norwegian Institute of Public Health, Oslo, Norway, Dept. of Preventive Medicine, International Kazakh – Turkish University, Turkestan, Kazakhstan, International School of Public Health, Northern State Medical University, Arkhangelsk, Russia,Corresponding Author:
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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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Moon S, Lee SH, Ryoo HW, Kim JK, Ahn JY, Kim SJ, Jeon JC, Lee KW, Sung AJ, Kim YJ, Lee DR, Do BS, Park SR, Lee JS. Preventable trauma death rate in Daegu, South Korea. Clin Exp Emerg Med 2015; 2:236-243. [PMID: 27752603 PMCID: PMC5052913 DOI: 10.15441/ceem.15.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/15/2015] [Accepted: 10/18/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study investigated the preventable death rate in Daegu, South Korea, and assessed affecting factors and preventable factors in order to improve the treatment of regional trauma patients. METHODS All traumatic deaths between January 2012 and December 2012 in 5 hospitals in Daegu were analyzed by panel review, which were classified into preventable and non-preventable deaths. We determined the factors affecting trauma deaths and the preventable factors during trauma care. RESULTS There were overall 358 traumatic deaths during the study period. Two hundred thirty four patients were selected for the final analysis after excluding cases of death on arrival, delayed death, and unknown causes. The number of preventable death was 59 (25.2%), which was significantly associated with mode of arrival, presence of head injury, date, and time of injury. A multivariate analysis revealed that preventable death was more likely when patients were secondly transferred from another hospital, visited hospital during non-office hour, and did not have head injuries. The panel discovered 145 preventable factors, which showed that majority of factors occurred in emergency departments (49.0%), and were related with system process (76.6%). CONCLUSION The preventable trauma death rate in Daegu was high, and mostly process-related.
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Affiliation(s)
- Sungbae Moon
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Suk Hee Lee
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong Kun Kim
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Yun Ahn
- Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sung Jin Kim
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Cheon Jeon
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Woo Lee
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Ae Jin Sung
- Department of Emergency Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Yun Jeong Kim
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Dae Ro Lee
- Department of Emergency Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Byung Soo Do
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sin Ryul Park
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Jin-Seok Lee
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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Park CY, Yu B, Kim HH, Hwang JJ, Lee J, Cho HM, Park HN. PARK Index for Preventable Major Trauma Death Rate. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.3.115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chan Yong Park
- Department of Trauma Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byungchul Yu
- Department of Trauma Surgery, Gachon University Medical Center, Incheon, Korea
| | - Ho Hyun Kim
- Department of Trauma Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jung Joo Hwang
- Department of Trauma Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jungnam Lee
- Department of Trauma Surgery, Gachon University Medical Center, Incheon, Korea
| | - Hyun Min Cho
- Department of Trauma Surgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Han Na Park
- Coordinator, Trauma Center, Pusan National University Hospital, Busan, Korea
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Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system. J Trauma Acute Care Surg 2015; 78:1168-75. [PMID: 26151519 DOI: 10.1097/ta.0000000000000663] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. METHODS Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. RESULTS Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). CONCLUSION Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. LEVEL OF EVIDENCE Prognostic study, level III.
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Kim SC, Song KJ, Shin SD, Lee SC, Park JO, Holmes JF. Preventable deaths in patients with traumatic brain injury. Clin Exp Emerg Med 2015; 2:51-58. [PMID: 27752573 PMCID: PMC5052850 DOI: 10.15441/ceem.14.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 12/25/2014] [Accepted: 01/08/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the rate of and etiology for preventable deaths in patients with traumatic brain injuries (TBIs). METHODS We conducted a retrospective, multicenter review of patients with TBIs who died within 7 days of their traumatic event from June 2008 to May 2009. Three board certified emergency physicians independently reviewed every case using a structured survey format. Cases were considered preventable deaths only if all physicians independently agreed the death was preventable. Management errors contributing to the preventable death were determined. RESULTS Forty-one patients who died from TBI were eligible. Preventable deaths were identified in nine (22%; 95% confidence interval [CI], 11 to 28) cases. Fifty-six management errors were identified including 36 (64%; 95% CI, 50 to 77) in the emergency department and 13 (23%; 95% CI, 13 to 36) in the prehospital phase. Thirty (54%; 95% CI, 40 to 67) management errors were process-related, and 26 (46%; 95% CI, 33 to 60) were structure-related. CONCLUSION An important and measurable rate of preventable mortality occurs in the initial care of TBI patients. Errors were common and most occurred in the emergency department. In addition, errors were common in the prehospital phase but did not always lead to mortality. When analyzed by type of problem, both process-related and structure-related errors occurred in similar proportions.
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Affiliation(s)
- Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Chul Lee
- Department of Emergency Medicine, Dongkuk University College of Medicine, Ilsan, Korea
| | - Ju Ok Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - James F. Holmes
- Department of Emergency Medicine, UC Davis Medical Center (JFH), Davis, CA, USA
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Schueller G, Scaglione M, Linsenmaier U, Schueller-Weidekamm C, Andreoli C, De Vargas Macciucca M, Gualdi G. The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology. Radiol Med 2015; 120:641-54. [PMID: 25634793 DOI: 10.1007/s11547-015-0500-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/13/2015] [Indexed: 12/15/2022]
Abstract
Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.
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Chiara O, Mazzali C, Lelli S, Mariani A, Cimbanassi S. A population based study of hospitalised seriously injured in a region of Northern Italy. World J Emerg Surg 2013; 8:32. [PMID: 23937969 PMCID: PMC3751444 DOI: 10.1186/1749-7922-8-32] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 08/05/2013] [Indexed: 02/03/2023] Open
Abstract
Background Injury is a public health problem in terms of mortality, morbidity and disability. The implementation of a regionalised trauma system has been proved to significantly reduce the social impact of severe trauma on population. A population-based registry may be useful to obtain reliable epidemiologic data. Aim To perform an exhaustive analysis of severe trauma patients hospitalised in Lombardia, a region of northern Italy. Materials and methods The regional Hospital Discharge Registry (HDR) was used to retrieve data of all patients who suffered from serious injuries from 2008 to 2010. ICD9-CM codes of discharge diagnoses were analysed and patients coded from 800.0 to 939.9 or from 950.0 to 959.9 have been retrieved. Femur fractures in elderly and patients with length of hospital stay less than 2 days were excluded. Patients have been considered seriously injured if discharged dead or any of followings: admission or transit in ICU, need of mechanical ventilation, tracheotomy, invasive hemodynamic monitoring. Average reimbursement based on DRG has been evaluated. Statistics Student’s t test, ANOVA for continuous data, chi-square test for categorical data were used, and a p value less than 0.05 was considered significant. Results The severely injured patients hospitalised in Lombardia in three years were 11704, 391 per million per year. Overall mortality was 24.17% and increased with age. Males aging from 18 to 64 years had more occupational injuries, trauma on the road and violence by others. Females were more susceptible to domestic injuries and self inflicted violence, mostly in older ages. Acute mortality was higher after traffic accidents, while late mortality was increased in domestic trauma. Pediatric cases were unusual. A significant increase (+10.18%) in domestic trauma, with a concomitant decrease (-17.76%) in road-related accidents was observed in the three years study period. Reimbursement paid to hospitals for seriously injured was insufficient with regard to estimated costs of care. Conclusion Serious injury requiring hospitalisation in Lombardia is still an healthcare problem, with a trend toward a decrease of traffic accidents, increase in domestic trauma and involvement of older people. These results may help to plan a new regionalised Trauma System.
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Affiliation(s)
- Osvaldo Chiara
- Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca'Granda, Piazza Ospedale Maggiore 3, Milan, 20162, Italy
| | - Cristina Mazzali
- Universita' di Milano, Dip, Scienze cliniche Luigi Sacco, Milan, Italy
| | - Sofia Lelli
- Quality Department, Ospedale Niguarda Ca'Granda Milan, Milan, Italy
| | - Anna Mariani
- Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca'Granda, Piazza Ospedale Maggiore 3, Milan, 20162, Italy
| | - Stefania Cimbanassi
- Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca'Granda, Piazza Ospedale Maggiore 3, Milan, 20162, Italy
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Moon JH, Seo BR, Jang JW, Lee JK, Moon HS. Evaluation of probability of survival using trauma and injury severity score method in severe neurotrauma patients. J Korean Neurosurg Soc 2013; 54:42-6. [PMID: 24044080 PMCID: PMC3772286 DOI: 10.3340/jkns.2013.54.1.42] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/08/2013] [Accepted: 07/17/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Despite several limitations, the Trauma Injury Severity Score (TRISS) is normally used to evaluate trauma systems. The aim of this study was to evaluate the preventable trauma death rate using the TRISS method in severe trauma patients with traumatic brain injury using our emergency department data. Methods The use of the TRISS formula has been suggested to consider definitively preventable death (DP); the deaths occurred with a probability of survival (Ps) higher than 0.50 and possible preventable death (PP); the deaths occurred with a Ps between 0.50 and 0.25. Deaths in patients with a calculated Ps of less than 0.25 is considered as no-preventable death (NP). A retrospective case review of deaths attributed to mechanical trauma occurring between January 1, 2011 and December 31, 2011 was conducted. Results A total of 565 consecutive severe trauma patients with ISS>15 or Revised Trauma Score<7 were admitted in our institute. We excluded a total of 24 patients from our analysis : 22 patients younger than 15 years, and 2 patients with burned injury. Of these, 221 patients with head injury were analyzed in the final study. One hundred eighty-two patients were in DP, 13 in PP and 24 in NP. The calculated predicted mortality rates were 11.13%, 59.04%, and 90.09%. The actual mortality rates were 12.64%, 61.547%, and 91.67%, respectively. Conclusion Although it needs to make some improvements, the present study showed that TRISS performed well in predicting survival of traumatic brain injured patients. Also, TRISS is relatively exact and acceptable compared with actual data, as a simple and time-saving method.
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Affiliation(s)
- Jung-Ho Moon
- Department of Neurosurgery, Chonnam National University Hospital & Medical School, Gwangju, Korea
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Trauma center performance indicators for nonfatal outcomes: a scoping review of the literature. J Trauma Acute Care Surg 2013; 74:1331-43. [PMID: 23609287 DOI: 10.1097/ta.0b013e31828c4787] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND According to Donabedian's framework, outcomes covering the following six domains should be used to evaluate health care quality: death, adverse events, readmissions to hospital, resource use, quality of life, and ability to function in daily activities. The objective of this study was to identify the nonfatal outcomes that have been used to evaluate the performance of trauma hospitals. Secondary objectives were to describe definitions and methodological quality. METHODS We performed a scoping literature review of studies using at least one nonfatal outcome to evaluate the performance of acute care hospitals for the treatment of general trauma populations. We searched MEDLINE, EMBASE, Cochrane central, CINAHL, BIOSIS, TRIP and ProQuest databases. Methodological quality was evaluated using elements of the STROBE statement and the Downs and Black tool. RESULTS Of 14,521 citations, 40 were eligible for inclusion. We identified 14 nonfatal outcomes as follows: (i) adverse events including complications (used in 35 evaluations), missed injuries (n = 4), reintubation (n = 2), unplanned intensive care unit admissions (n = 2), and unplanned surgeries (n = 4); (ii) resource use including hospital (n = 19), intensive care unit (n = 15), and ventilator (n = 4) length of stay, inappropriate hospital stay (n = 1), and potentially unnecessary care (n = 1); (iii) hospital readmissions (n = 4); and (iv) ability to function in daily activities including functional capacity (n = 2), and discharge destination (n = 3). No measures of quality of life were identified. There was high heterogeneity in the definitions used. Only 18% of studies had high methodological quality. CONCLUSION Among recommended domains of nonfatal outcomes, adverse events and resource use were frequently used to evaluate trauma care, readmissions and function in daily activities were rarely used, and quality of life was never used. In addition, definitions of nonfatal outcomes were variable, and methodological quality was low. There is a need to develop valid and reliable performance indicators based on each domain of Donabedian's framework to evaluate trauma care.
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Lansink KWW, Gunning AC, Leenen LPH. Cause of death and time of death distribution of trauma patients in a Level I trauma centre in the Netherlands. Eur J Trauma Emerg Surg 2013; 39:375-83. [PMID: 26815398 DOI: 10.1007/s00068-013-0278-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/12/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The classical trimodal distribution of trauma deaths describes three peaks of deaths following trauma: immediate, early and late deaths. The aim of this study was to evaluate whether further maturation of the trauma centre and the improvement of survival have had an effect on the time of death distribution and resulted in a shift in causes of death. METHODS All trauma patients from 1999 to 2010 who died after arrival in the emergency room and prior to discharge from the hospital were included. Deaths caused by drowning, poisoning and overdose were excluded. RESULTS A total of 16,421 trauma patients were admitted to our hospital. 772 (4.7 %) patients died, of which 720 were included in this study. The trauma mechanism was predominantly blunt (94.7 %). 530 patients (73.6 %) had Injury Severity Score (ISS) ≥25. The most frequent causes of death were central nervous system (CNS) injury (59.9 %), exsanguinations (12.9 %) and pneumonia/respiratory insufficiency (8.5 %). The first peak of death was seen in the first hour after arrival at the emergency department; subsequently, a rapid decline was observed and no further peaks were seen. Over the years, we observed a general decrease in deaths due to exsanguination (p = 0.035) and a general increase in deaths due to CNS injury (p = 0.004). CONCLUSION The temporal distribution of trauma deaths in our hospital changed as maturation of the trauma centre occurred. There is one peak of trauma deaths in the first hour after admission, followed by a rapid decline; no trimodal distribution was observed. Over time, there was a decrease in exsanguinations and an increase of deaths due to CNS injury.
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Affiliation(s)
- K W W Lansink
- Department of Surgery, University Medical Center Utrecht, Suite G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - A C Gunning
- Department of Surgery, University Medical Center Utrecht, Suite G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Suite G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Trauma center performance indicators for nonfatal outcomes: A scoping review of the literature. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A comparison of methods to obtain a composite performance indicator for evaluating clinical processes in trauma care. J Trauma Acute Care Surg 2013; 74:1344-50. [DOI: 10.1097/ta.0b013e31828c32f2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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A comparison of methods to obtain a composite performance indicator for evaluating clinical processes in trauma care. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Moore L, Lavoie A, Sirois MJ, Swaine B, Murat V, Sage NL, Emond M. Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system. J Emerg Trauma Shock 2013; 6:3-10. [PMID: 23492970 PMCID: PMC3589856 DOI: 10.4103/0974-2700.106318] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 04/08/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data. MATERIALS AND METHODS Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005). RESULTS Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03). CONCLUSION This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Laval University, Quebec (Qc), Canada ; Unité de Traumatologie-urgence-soins Intensifs, Center de Recherche du CHA (Hôpital de l'Enfant-Jésus), Laval University, Quebec (Qc), Canada
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Dijkema LM, Dieperink W, van Meurs M, Zijlstra JG. Preventable mortality evaluation in the ICU. Crit Care 2012; 16:309. [PMID: 22546292 PMCID: PMC3681346 DOI: 10.1186/cc11212] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Mortality is the most widely measured outcome parameter. Improvement of this outcome parameter in critical care is nowadays expected not to come from new technologies or treatment, but from delivering the right care at the right moment in a safe way. The measurement of mortality as an outcome parameter confronts us with a problem in providing follow-up to the results. Especially when proven structure and process interventions are applied already, the cause of a suboptimal performance cannot be deduced easily. One possibility is to evaluate the causes of death and to judge preventability. In this article we explore the opportunities and difficulties of a tool to evaluate preventable mortality in the ICU.
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Affiliation(s)
- L Marjon Dijkema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
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Tan JN, Burke PA, Agarwal SK, Mantilla-Rey N, Quillen K. A massive transfusion protocol incorporating a higher FFP/RBC ratio is associated with decreased use of recombinant activated factor VII in trauma patients. Am J Clin Pathol 2012; 137:566-71. [PMID: 22431532 DOI: 10.1309/ajcpqznchm5pik8o] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
We implemented a protocol incorporating a higher fresh frozen plasma (FFP)/RBC ratio for the management of trauma patients requiring massive transfusion in 2007. This study aims to identify issues that affected the effective deployment of the massive transfusion protocol (MTP) and compare outcome variables with a historic cohort. Data from 49 trauma patients who received at least 10 units of packed RBCs within 24 hours were analyzed and compared with a historic massively transfused cohort who had received recombinant activated factor VII (rFVIIa). Of the patients, 28 received an FFP/RBC ratio of 1:1 to 1:2; 12 received a lower ratio of 1:2 to 1:4; 3 received more than 1:1 and 6 had less than 1:4. Compared with the historic cohort, the 1:1-1:2 group received significantly fewer blood components and did not require rescue rFVIIa. An MTP incorporating a higher FFP/RBC ratio of 1:1 to 1:2 is associated with decreased use of blood components and may obviate the need for rFVII.
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Settervall CHC, Domingues CDA, Sousa RMCD, Nogueira LDS. Preventable trauma deaths. Rev Saude Publica 2012; 46:367-75. [PMID: 22310649 DOI: 10.1590/s0034-89102012005000010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 09/15/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe methods of estimation and assess preventable deaths and types of errors related to health care. METHODS A systematic review of articles on preventable trauma deaths published between 2000 and 2009 was conducted. Lilacs, SciELO and Medline databases were searched using the keywords "trauma," "avoidable," "preventable," "interventions" and "complications" and the health sciences descriptors "death," "cause of death," and "hospitals." RESULTS A total of 29 articles published during the study period were selected. Most were retrospective studies (96.5%). The most common methods used to define avoidability of death were expert panel and injury severity scores. Deaths were categorized as follows: preventable; potentially preventable; and not preventable. The mean preventable death rate was 10.7% (SD 11.5%). The most commonly reported errors were inadequate care management of injured patients and evaluation and treatment errors. CONCLUSIONS Inconsistent terms were used to categorize deaths and related noncompliances. It is suggested to standardize the terminology for the classification of deaths and types of errors.
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Sallum AMC, Sousa RMCD. Diagnósticos de enfermagem em vítimas de trauma nas primeiras seis horas após o evento. ACTA PAUL ENFERM 2012. [DOI: 10.1590/s0103-21002012000200016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Identificar a frequência dos diagnósticos de enfermagem em vítimas de trauma nas primeiras 6 horas, após o evento traumático e verificar a relação desses diagnósticos com a mortalidade. MÉTODOS: Estudo prospectivo transversal com análise quantitativa, realizado em hospital terciário, centro de referência ao trauma no Município de São Paulo. Durante seis meses, foram avaliados 407 pacientes maiores de 18 anos atendidos no Pronto -Socorro desse hospital. RESULTADOS: Os diagnósticos de enfermagem mais frequentes foram: Risco de Infecção (84,5%), Integridade da pele prejudicada (77,9%), Dor aguda (71,5%), Conforto prejudicado (68,3%) e Integridade tissular prejudicada (54,1%). A associação entre diagnósticos de enfermagem e mortalidade foi observada em 28 (66,7%) dos diagnósticos identificados. CONCLUSÃO: Os dados acrescentaram informações que poderão auxiliar na formação e atuação do enfermeiro no cenário das emergências em trauma e evidenciaram o potencial dos diagnósticos de enfermagem para avaliar os resultados e a qualidade da assistência.
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Schluter PJ. The Trauma and Injury Severity Score (TRISS) revised. Injury 2011; 42:90-6. [PMID: 20851394 DOI: 10.1016/j.injury.2010.08.040] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Revised: 08/25/2010] [Accepted: 08/26/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Trauma and Injury Severity Score (TRISS) remains the most commonly used tool for benchmarking trauma fatality outcome. Recently, it was demonstrated that the predictive power of TRISS could be substantially improved by re-classifying the component variables and treating the variable categories nominally. This study aims to develop revised TRISS models using re-classified variables, to assess these models’ predictive performances against existing TRISS models, and to identify and recommend a preferred TRISS model. MATERIALS AND METHODS Revised TRISS models for blunt and penetrating injury mechanism were developed on an adult (aged 15 years) sample from the National Trauma Data Bank National Sample Project (NSP), using 5-category variable classifications and weighted logistic regression. Their predictive performances were then assessed against existing TRISS models on the unweighted NSP, National Trauma Data Bank (NTDB), and New Zealand Database (NZDB) samples using area under the Receiver Operating Characteristic curve (AUC) and Bayesian Information Criterion (BIC) statistics. RESULTS The weighted NSP sample included 1,124,001 adults with blunt or penetrating injury mechanism events and known discharge status, of whom 1,061,709 (94.5%) survived to discharge. Complete information for all TRISS variables was available for 896,212 (79.7%). Revised TRISS models that included main-effects and two-factor interaction terms had superior AUC and BIC statistics to main effects models and existing TRISS models for patients with complete data in NSP, NTDB and NZDB samples. Predictive performance decreased as the number of variables with missing values included within revised TRISS models increased, but model performances generally remained superior to existing TRISS models. DISCUSSION Revised TRISS models had importantly improved predictive capacities over existing TRISS models. Additionally, they were easily computed, utilised only those variables already collected for existing TRISS models, and could be applied and produce meaningful survival probabilities when one or more of the predictor variables contained missing values. The preferred revised TRISS model included main-effects and two-factor interaction terms and allowed for missing values in all predictor variables. A strong case exists for replacing existing TRISS models in trauma scoring systems benchmarking software with this preferred revised TRISS model.
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Affiliation(s)
- Philip J Schluter
- AUT University, School of Public Health and Psychosocial Studies, Auckland, New Zealand.
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Abstract
PURPOSE OF REVIEW Injury is a leading cause of pediatric death and disability. Although adult trauma care in the United States has been celebrated as a model system of emergency care, it is not clear that pediatric trauma care is as well organized. We seek to describe in this review the current state of pediatric trauma care and suggest next steps required to ensure the efficient delivery of pediatric trauma care. RECENT FINDINGS Eighty-four percent of adults in the United States have access to a level 1 or 2 trauma center within an hour, and 71.5% of pediatric patients have access to a verified pediatric trauma center within an hour assuming ground and air transport. These results are variable depending on state, region, and population density. An estimated 17.4 million children do not have access to a pediatric trauma center within 60 min. SUMMARY Trauma centers improve outcome for injured patients with care at pediatric-focused centers superior to that provided at nonpediatric centers. However, access to high-level trauma care varies geographically and is not available to all children in a timely fashion. Future studies should correlate access to outcome and guide policy makers to optimize trauma systems for children.
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Affiliation(s)
- Brendan G Carr
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Alted López E. Pro Centros de Trauma. Med Intensiva 2010; 34:188-93. [DOI: 10.1016/j.medin.2009.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 11/16/2009] [Accepted: 11/18/2009] [Indexed: 02/03/2023]
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