Anesthetic deaths in a developing country

It is important to ascertain the contribution of anesthesia to perioperative mortality in order to enable improvement in the safety and quality of care. Scanty literature regarding anesthetic mortality from developing countries is available. We present data regarding anesthesia related mortality in a university hospital in a developing country. We reviewed all patient deaths occurring between 1992-2003 occurring within 24 hours of anesthesia, as part of departmental quality assurance activity. The aim of study was to identify any contributing factors associated with mortality, and to compare our data with similar studies from developed and developing countries. 111,289 cases were handled in this period. Within 24 hours the crude mortality was 35 (3.14: 10,000). 3 patients died at induction, 13 intraoperatively and one at emergence. In the postoperative period 18 (51%) cases of mortality occurred. In 4 (11%) cases anesthesia was found to be solely responsible (0.35 per 10,000), in 8 (23%) cases anesthesia was found to be partially responsible (0.7 per 10,000). In 23 patient disease and surgical factors played a primary role. In 10 (28.5%) cases deaths were considered to be avoidable. Two time periods were also compared. Between 1992-1998 anesthesia mortality was 0.68: 10,000 anesthetics, and from 1999-2003 it was 0.18: 10,000 Higher mortality was observed with advancing age, higher ASA status, emergency and complex surgical procedures. Human factor, human error, inadequate preoperative preparation, inappropriate postoperative care and lack of supervision were identified as preventable factors.     

Chest trauma in a developing country.

In a developing country with inadequate clinical facilities a conservative method of management of a major clinical problem is often the only rational approach. This policy was adopted in the management of 145 patients with chest trauma in a teaching hospital in Nigeria. Automobile accidents were the cause of the thoracic injuries in 73.1% of the patients; 71.7% of the patients were managed as in-patients. The management of the patients was essentially aimed at correction of hypovolaemia, tube drainage of pleural collections, and relief of pain by intercostal nerve block. Major operative procedures were adopted in 11 cases (7.6%) for persistent haemothorax or for pyothorax, ruptured diaphragm, ruptured abdominal viscus, and subdural haematona. No operative reduction of rib fractures was performed and only 1 of the 12 patients with flail chest was mechanically ventilated. The hospital mortality was 9.7% and, despite a high rate of default at follow-up attendances, no late death or serious complication was recorded. Th aspects peculiar to chest trauma in Nigeria are discussed.     

Financial burden of trauma care on a university hospital in a developing country.

BACKGROUND: Trauma care is expensive and more so for the hospitals not subsidized by the government, as is the case in developing countries. In this study, the burden of trauma care on a typical Level I trauma center in Turkey was investigated. METHODS: Medical, demographic, and financial records of trauma patients who were hospitalized in the calendar year of 1996 were analyzed. RESULTS: A total of 347 patients had complete data available for analysis. The mean Injury Severity Score was 13.3+/-0.5. Total hospital charges and charges per patient were $547,391 and $1,577, respectively. There was a positive correlation between the Injury Severity Score and the hospital charges. Although 54.2% of the patients were self-payer and the rest (45.8%) had some form of a health insurance, 5.5% ($30,496) of total hospital charges of these 347 trauma patients could not be collected by the hospital. CONCLUSION: Trauma care is expensive and reimbursement is not always possible, but the hospital's nonreimbursed money was within tolerable limits, and the overall financial balance of the hospital from the trauma care was on the positive side, even in the absence of government subsidy.     

Potentially preventable trauma deaths: A retrospective review

BackgroundReviewing 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.MethodsWe 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.ResultsOf 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.ConclusionsThe 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.     

Self-medication in a developing country

An interracial study on self-medication, including over-the-counter medication, as assessed by medications kept in the home, was carried out among a group of White, Indian and Black patients of differing sociocultural backgrounds. Whites had the most medications in their homes followed by urban Blacks, Indians and rural Blacks. The White section of the population appears to be as 'drug-dependent' as their counterparts elsewhere; the chain of events leading to this situation appears to be: sophistication + drug availability + social pressures = drug-dependence.     

Peritoneoscopy in a developing country

Peritoneoscopy in medical cases remains largely unpopular in the USA and the UK. In many developing countries there is often a heavy demand on medical facilities and the rapid diagnosis of intra-abdominal problems is of major importance. We present a series of 193 patients in whom peritoneoscopy was carried out during a 2 1/2-year period. Eighty-six per cent (166) of examinations yielded information of positive diagnostic value. The most common diagnoses were hepatocellular carcinoma, liver cirrhosis, bilharzial fibrosis and peritoneal tuberculosis. The peritoneoscopic appearances in the various lesions are illustrated and discussed. Peritoneoscopy is a safe procedure and its value in a developing country is great, both in terms of economy of man-hours employed and, more particularly, of diagnostic yield.     

Prospective audit of deaths at a teaching hospital

We undertook a prospective audit of all the deaths in the trauma unit, the emergency unit, and the intensive care units to estimate the number of potential organ donors in the hospital and identify the reasons for nonreferral of potential donors. The transplant coordinators undertook daily visits to the above units and documented all of the deaths occurring in the previous 24 hours. The patient records were reviewed, and the medical and nursing staff interviewed to determine the precise circumstances surrounding the death. Seven of the 14 deaths in the neurosurgical intensive care unit were related to the head injury, and five were certified brain dead and referred as an organ donor. Fifty-eight of 83 deaths in the trauma unit were head injury related; however, only eight were eventually certified brain dead and referred. In the emergency unit, only one of 76 patients who died was certified brain dead and referred as an organ donor. Although many of the deaths in the above units are related to a head injury or cerebral event, very few are actually certified brain dead. All potential donors who were certified brain dead were referred to the transplant team.     

Preventable deaths in a self-designated trauma system

Organized paramedic care was established in 1974 in Hillsborough County, Florida, with subsequent development of a hospital self-designation system for trauma in 1980. To evaluate the level of trauma care in the county, a review of trauma deaths in 1984 was performed. A total of 452 trauma deaths was identified. Of these, 191 deaths occurred at the scene. The remaining 261 patients were transported to one of six hospitals within the county. One hundred ninety-nine subsequent deaths were attributed to central nervous system (CNS) injury, while 62 deaths were secondary to non-CNS injuries. By the method of group review, 14 (22.6%) preventable non-CNS trauma deaths were identified. Six women died and eight men died; the mean age of the deceased was 44. Ten deaths (71.4%) were secondary to blunt trauma. Mean ISS score was 21.1. Eleven deaths (79%) were due to delay to the OR, 2 deaths (14%) were due to inadequate resuscitation, and 1 death (7%) was due to lack of surgical intervention. This study demonstrates that a self-designation system without regulatory control results in a high percentage of preventable trauma deaths. We conclude that established trauma systems are needed in all areas, including those that have had organized prehospital and hospital levels of care.     

Preventability of trauma deaths in a Dutch Level-1 trauma centre

Background

Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.

Methods

All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.

Results

Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.

Conclusions

The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.     

Trauma deaths in an Italian urban area: an audit of pre-hospital and in-hospital trauma care

In Italy, a comprehensive regional study of trauma deaths has never been performed. We examined the organization and delivery of trauma care in the city area of Milan, using panel review of trauma deaths. Two panels evaluated the appropriateness of care of all trauma victims occurred during 1 year, applying predefined criteria and judging deaths as not preventable (NP), possible preventable (PP), and definitely preventable (DP). Two hundred and fifty-five deaths were reviewed. Blunt trauma were 78.04% and motor vehicle crashes accounted for over 50%. Most victims (73.72%) died during pre-hospital settings and 91.1% died within the first 6h, principally because of central nervous system injuries in blunt and hemorrhage in penetrating trauma. Panels judged 57% of deaths NP, 32% PP, 11% DP (inter-panel K-test 0.88). Preventable deaths were higher after in-hospital admission. Main failures of treatment were lack in airway control or intravenous infusions in pre-hospital and mismanagement with missed injuries in emergency department.The high rate of avoidable deaths in Milan supports the need of trained pre-hospital personnel and of well equipped referring hospitals for trauma.     

Preventable trauma deaths: from panel review to population based-studies

Preventable trauma deaths are defined as deaths which could be avoided if optimal care has been delivered. Studies on preventable trauma deaths have been accomplished initially with panel reviews of pre-hospital and hospital charts. However, several investigators questioned the reliability and validity of this method because of low reproducibility of implicit judgments when they are made by different experts. Nevertheless, number of studies were published all around the world and ultimately gained some credibility, particularly in regions where comparisons were made before and after trauma system implementation with a resultant fall in mortality. During the last decade of century the method of comparing observed survival with probability of survival calculated from large trauma registries has obtained popularity. Preventable trauma deaths were identified as deaths occurred notwithstanding a high calculated probability of survival. In recent years, preventable trauma deaths studies have been replaced by population-based studies, which use databases representative of overall population, therefore with high epidemiologic value. These databases contain readily available information which carry out the advantage of objectivity and large numbers. Nowadays, population-based researches provide the strongest evidence regarding the effectiveness of trauma systems and trauma centers on patient outcomes.     

Burn survival in a developing country

This paper presents survival rates among 533 burn patients admitted to the University of the Philippines-Philippines General Hospital Medical Center from 1969 to 1976. Mean burn size was 2357 per cent and the mean age was 1827 years. Survival in burns of less than 20 per cent has remained excellent, but in burns of 60 per cent and over survival has remained very poor. Comparison of survival rates with figures from the National Burn Information Exchange in the United States shows surprisingly similar results.     

Epidemiology of trauma deaths

The records of all 437 persons who died from trauma in San Francisco in 1977 were examined. Sixty-five percent of the sample (285 were younger than 50 years, and 119 were between ages 21 and 30. Gunshot wounds (140 or 32 percent) and falls (122 or 28 percent) were the most common causes of injury. Fifty-three percent of the sample were dead at the scene of injury before transport could be accomplished, 7.5 percent died in the emergency room, and 39.5 percent died in the hospital. Fifty-five percent of the 359 patients who died within the first 2 days died from brain injury, while 78 percent of the 55 late deaths were due to sepsis and multiple organ failure. In 10 cases (2 percent), death was due to delayed transport or to errors in diagnosis and treatment and was deemed preventable. The key areas in which advances are necessary in order to reduce the number of trauma deaths are prevention of trauma, more rapid and skilled transport of injured victims, better early management of primary brain injuries, and more effective treatment of the late complications of sepsis and multiple organ failure.     

Intensive care in a developing country: a review of the first 100 cases.

The role of an intensive care unit with regard to patient care and manpower training in a developing country was considered from an analysis of the first 100 admissions to the unit. The organisation and facilities available are outlined. The majority of cases admitted were post-surgical but the best results were achieved in training the nursing and medical staff to manage peritoneal dialysis and patients with eclampsia. Despite the lack of equipment and investigative facilities the overall mortality was 30%.