Evaluation of pediatric trauma care in Ontario

Three hundred sixty-seven consecutive pediatric trauma deaths which occurred in Ontario between 1985 and 1987 were analyzed from the coroners' records. Injuries were classified as survivable or unsurvivable, and a preventable death rate of 20% was identified. Rural preventable deaths occurred mainly before arrival at hospital, but 55% of urban preventable deaths occurred in hospitals. The causes of death in children with survivable injury suggest that the institution of prehospital resuscitation and improvement in trauma care education for physicians might reduce mortality. The high incidence of unsurvivable injury suggests that injury prevention will be more cost effective in the long term.     

Preventable trauma deaths in The Netherlands--a prospective multicenter study

The data of all trauma fatalities occurring in 12 Dutch hospitals during a period of 1 year were reviewed for management errors and preventable deaths by a panel of five surgeons trained in trauma care. Management errors occurred in 38% of the fatalities. There was a significantly higher percentage of management errors in small general hospitals (72%) than in large general (29%) and in university hospitals (34%). A (possibly or definitely) preventable cause of death was identified in 25% of the fatalities. There was a significantly higher preventable cause of death rate in small general hospitals than in both other hospital categories. Of all fatalities, 21% were classified as preventable deaths. A significantly higher preventable death rate occurred in small general hospitals (48%), than in large general (14%) and university hospitals (19%). From these results, it can be concluded that management errors and preventable deaths are general phenomena occurring in any hospital. However, they occur significantly more frequently in hospitals not especially equipped to manage severely injured patients.     

Preventable trauma deaths: Dade County, Florida

We reviewed 1,201 trauma deaths that occurred in Dade County, Florida, in 1982 in order to evaluate the need for an organized trauma network. There were 715 deaths (59.5%) at the scene. Of the remaining 486 patients who were transported to hospitals for treatment there were 240 central nervous system (CNS) deaths and 246 non-CNS deaths. Fifty-two (21.1%) preventable non-CNS trauma deaths were identified out of the 246 non-CNS deaths. The lack of an appropriate surgical procedure or a delay to surgery accounted for 82.7% of the preventable deaths. The preventable non-CNS death rate was 12.1% at the then functional Level I hospital and 26.4% at the other 22 hospitals (p less than 0.01). The ISS scores were similar for both the functional Level I hospital and the other hospitals. A trauma network involving seven hospitals is currently being established in Dade County, Florida. Applying the 1982 data to these hospitals reveals a preventable non-CNS death rate of 12.1% for the Level I hospital, 21.5% for the six planned Level II hospitals, and 30.0% for the other 16 hospitals. We conclude that: the severely injured should be triaged directly to trauma centers, and there is a need in Dade County, Florida, for an organized trauma system.     

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.     

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.     

Peer review audit of trauma deaths in a developing country

OBJECTIVES: Peer review of trauma deaths can be used to evaluate the efficacy of trauma systems. The objective of this study was to estimate teh proportion of preventable trauma deaths and the factors contributing to poor outcome using peer review in a tertiary care hospital in a developing country. METHODS: All trauma deaths during a 2-year period (1 January 1998 to 30 December 1998) were identified and registered in a computerized trauma registry, and the probability of survival was calculated for all patients. Summary data, including registry information and details of prehospital, emergency room, and definitive care, were provided to all members of the peer review committee 1 week before the committee meeting. The committee then reviewed all cases and classified each death as preventable, potentially preventable, or non-preventable. RESULTS AND CONCLUSION: A total fo 279 patients were registered in the trauma registry during the study period, including 18 trauma deaths. Peer review judged that six were preventable, seven were potentially preventable, and four were non-preventable. One patient was excluded because the record was not available for review. The proportion of preventable and potentially preventable deaths was significantly higher in our study than from developed countries. Of the multiple contributing factors identified, the most important were inadequate prehospital transfer, limited hospital resources, and an absence of integrated and organized trauma care. This study summarizes the challenges faced in trauma care in a developing country.     

The significance of critical care errors in causing preventable death in trauma patients in a trauma system

The regionalization of trauma care has led to a decrease in preventable death after injury. This decrease has been attributed to earlier resuscitation and surgical intervention. Little emphasis, however, has focused on the critical care phase of trauma patient management. This study was undertaken to determine the significance of critical care errors (CCEs) on preventable mortality and morbidity in a regionalized system of trauma care. The records of 12,910 trauma patients admitted to six trauma centers over a three-year period were reviewed. The cause and preventability of death was determined by a panel of trauma experts. Critical care errors occurred in 151 (23%) of all patients with errors occurring during any phase of care. The CCEs were identified in 38 of 125 (30%) deaths of patients with errors in some phase of care. The CCEs were implicated as the cause of death in 30 (48%) of the 62 preventable deaths. The proportion of preventable deaths attributable to CCEs was higher than the proportion of preventable death attributable to errors in the resuscitative and operative phases of care (p less than 0.001, chi-square). These data indicate that CCEs significantly contribute to preventable mortality and morbidity in trauma patients. It is imperative that physicians caring for trauma patients possess expertise in the critical care management of injured patients.     

Analyses of preventable deaths by mechanism of injury among 13,500 trauma admissions.

Preventable deaths (PD) were evaluated by mechanism of injury for 13,500 trauma admissions to eight hospitals over 2 years. There were 42 (3.3%) hospital deaths. Preventable deaths were analyzed by time of death, anatomic site of injury, and mechanism; penetrating (PEN) and blunt with low fall (LF) injuries were considered separately. Preventability of death for patients with probability of survival of less than 0.5, "unexpected deaths," after penetrating and blunt injuries, was determined by consensus of three trauma surgeons. Twelve per cent of deaths were found to be possibly preventable. The incidence of preventable deaths did not differ significantly across groups. Factors in preventable deaths varied by injury cause; delays in operation, PEN (50%), and blunt injury patients (48%); management errors, blunt (52%) and LF (84%); and technical errors, PEN (37.5%). Median times to death were significantly different by cause of injury: PEN, 3 hours; blunt, 13 hours; and LF, 3975 hours. Problems were identified in the hospital care of patients, especially those with LF, leading to sepsis and multiple organ failure.     

Preventable deaths from hemorrhage at a level I Canadian trauma center

BACKGROUND: Studies of trauma deaths have had a tremendous impact on the quality of contemporary trauma care. We studied causes of trauma death at a Level I Canadian trauma center, and tabulated preventable deaths from hemorrhage using explicit criteria. METHODS: Trauma registry data were used to identify all trauma deaths at our institution from January 1, 1999 to December 31, 2003. Demographics, mechanism, and time or location of death were recorded. Registry data analysis and selective chart or autopsy review were then performed to assign causes of death. RESULTS: A total of 558 consecutive trauma deaths were reviewed. Mean age was 48.7 (46.7-50.6), and mean Injury Severity Score was 38.8 (37.6-40.0); 29% were females. Blunt trauma represented 87% of all cases; penetrating injuries were only 13%. Central nervous system (CNS) injuries were the most frequent cause of death (60%), followed by hemorrhage (15%), and then combination CNS and hemorrhagic injuries (11%). Multiple organ failure caused 5% of deaths and 9% of deaths were from other causes. Of hemorrhagic deaths, 48% (n = 41) were from blunt injury, and 52% (n = 45) were from a penetrating mechanism. Of these hemorrhagic deaths, 16% were judged to be preventable because of significant delays in identifying the major source of hemorrhage. Hemorrhage from blunt pelvic injury was the major cause of exsanguination in 12 of 14 of these preventable deaths. CONCLUSIONS: Blunt injury is the major mechanism leading to trauma deaths. Massive bleeding from blunt pelvic injury is the major cause of preventable hemorrhagic deaths in our study.     

Critical care issues in the early management of severe trauma

Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.     

Inter-rater reliability of preventable death judgments. The Preventable Death Study Group.

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.     

Evaluation of management of road trauma survivors with brain injury and neurologic disability in Victoria

BACKGROUND: Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999. METHODS: The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records. RESULTS: The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units. CONCLUSION: Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury 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.     

Effect of a voluntary trauma system on preventable death and inappropriate care in a rural state

BACKGROUND: This study compares the preventable death rate and the nature and degree of inappropriate care in a rural state before and after implementation of a voluntary trauma system. METHODS: Deaths attributed to mechanical trauma occurring in the state of Montana between January 1, 1998, and December 31, 1998, were retrospectively reviewed by a multidisciplinary panel of physicians and nonphysicians representing the hospital and prehospital phases of care. Deaths were judged frankly preventable, possibly preventable, and nonpreventable. Care rendered in all categories was evaluated for appropriateness according to nationally accepted guidelines. Results were then compared with an identical study conducted before implementation of a voluntary trauma system. Measures to ensure comparability of the two studies were taken. RESULTS: Three hundred forty-seven (49%) of all trauma-related deaths met review criteria. The overall preventable death rate (PDR) was 8%. In those patients surviving to be treated at a hospital, the PDR was 15%. The overall rate of inappropriate care was 36%, 22% prehospital and 54% in-hospital. The majority of inappropriate care in all phases of care revolved around airway and chest injury management. The emergency department (ED) was the phase of care in which the majority of deficiencies were noted. In comparison with the results of the earlier study, PDR decreased (8% vs. 13%, p < 0.02). Adjusted rates of inappropriate care also showed a decrease (prehospital, 22% vs. 37%; ED, 40% vs. 68%; post-ED, 29% vs. 49%); however, the nature of deficiencies was the same. Population characteristics influencing interpanel reliability were similar for the two groups compared. Agreement on test cases presented to both panels was good (kappa statistic, 0.8). CONCLUSION: Implementation of a voluntary trauma system has positive effects on PDR and inappropriate care. The degree and nature of inappropriate care remain a concern. Mandated and funded system policies may further influence care positively.     

An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement.

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.     

The preventability of trauma-related death: A two-year cohort study in a trauma center in middle Taiwan

IntroductionThe preventable death rate (PDR) is an important parameter in the quality assurance of traumatic care. Medical errors or untimely management may occur during stressful trauma care, resulting in preventable deaths. We aimed to develop an applicable PDR model in a trauma center in middle Taiwan.Materials and MethodsWe identified adult trauma-related deaths which occurred from January 1, 2018 to December 31, 2019 at our hospital. Patients with a trauma and injury severity score (TRISS) <75% or ≥75% but with a chance of preventability, as determined by a trauma surgeon, were discussed by a panel comprising an emergency physician and surgeons specializing in different fields of medicine. Deaths were subsequently classified as definitely preventable (DP), potentially preventable (PP), or non-preventable (NP). Causes of DP or PP deaths were categorized as delayed diagnosis, delayed treatment, technical error, or inadequate infection prevention/control. The relationship between the time and cause of preventable deaths was also analyzed.ResultsThis study included 127 trauma-related deaths, of which 39 were discussed by the panel. Eight patients (6.3%) were categorized as DP, eight (6.3%) as PP, and 111 (87.4%) as NP. Among patients with preventable deaths, inadequate infection prevention/control, delayed treatment, delayed diagnosis, and technical error were identified in six (37.5%), five (31.2%), three (18.8%), and two (12.5%) patients, respectively. Four patients in the inadequate infection prevention/control group (4/6, 66.7%) died of aspiration pneumonia during the recovery phase.ConclusionA PDR evaluation model was developed and revealed that postoperative care is as important as a timely diagnosis and treatment to avoid preventable deaths following trauma.     

The influence of prehospital trauma care on motor vehicle crash mortality

BACKGROUND: This study evaluated the impact of the prehospital trauma care system on the mortality from motor vehicle crashes and on the temporal distribution between the crash and related death. METHODS: Autopsies performed by the Forensic Medical Institute on all deaths caused by motor vehicle crashes 1 year before and 1 year after the beginning of the prehospital trauma care system were evaluated. RESULTS: In the first period, 128 deaths occurred, 53.9% of them in the first hour after the crash, 36.7% between the first hour and the seventh day, and 9.4% after 1 week. In the second period, 115 deaths occurred, 40.8% of them in the first hour, 52.2% between the first hour and the seventh day, and 7% after 1 week. Central nervous system injury was the most frequent cause of death in both periods. Mortality was greatest among young people as well as male victims in both periods. CONCLUSION: After starting the prehospital trauma care system in our city, there was a decrease in the deaths occurring before hospital admission, a change in temporal distribution of deaths, and a reduction in the motor vehicle crash mortality rate.     

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.     

Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention

BACKGROUND: The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy. METHODS: Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury. RESULTS: Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of 相似文献   

Unexpected death on the non-ICU trauma ward

To characterize trauma patients who die unexpectedly on the ward (unexpected ward deaths = UWDs), 1,011 trauma-related deaths occurring at a level I trauma center over a 10-year period were reviewed for location of death. Seventy-four deaths occurred on the non-ICU trauma ward (i.e., nonmonitored med-surg floor). Fifty patients were "do not resuscitate" (expected deaths). Twenty-four patients (mean age, 58.0 years) died unexpectedly (2.4% of trauma-related deaths). The majority had a central nervous system injury or a precipitating event that occurred at night. Twelve (50%) of the UWDs were determined by peer review to be potentially preventable and were the result of delayed diagnosis (n = 6), aspiration (n = 3), or cardiorespiratory arrest (n = 3). We conclude that unexpected trauma center deaths related to events occurring on the non-ICU trauma ward (2.4% of trauma deaths) occur mostly at night in older, neurologically impaired patients and that half of these deaths may be potentially preventable. Increased awareness of this issue and an environment for direct patient observation may reduce the number of these potentially preventable deaths.