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.     

Survival prediction algorithms miss significant opportunities for improvement if used for case selection in trauma quality improvement programs

BackgroundQuality improvement (QI) programs have shown to reduce preventable mortality in trauma care. Detailed review of all trauma deaths is a time and resource consuming process and calculated probability of survival (Ps) has been proposed as audit filter. Review is limited on deaths that were ‘expected to survive’. However no Ps-based algorithm has been validated and no study has examined elements of preventability associated with deaths classified as ‘expected’. The objective of this study was to examine whether trauma performance review can be streamlined using existing mortality prediction tools without missing important areas for improvement.MethodsWe conducted a retrospective study of all trauma deaths reviewed by our trauma QI program. Deaths were classified into non-preventable, possibly preventable, probably preventable or preventable. Opportunities for improvement (OPIs) involve failure in the process of care and were classified into clinical and system deviations from standards of care. TRISS and PS were used for calculation of probability of survival. Peer-review charts were reviewed by a single investigator.ResultsOver 8 years, 626 patients were included. One third showed elements of preventability and 4% were preventable. Preventability occurred across the entire range of the calculated Ps band. Limiting review to unexpected deaths would have missed over 50% of all preventability issues and a third of preventable deaths. 37% of patients showed opportunities for improvement (OPIs). Neither TRISS nor PS allowed for reliable identification of OPIs and limiting peer-review to patients with unexpected deaths would have missed close to 60% of all issues in care.ConclusionsTRISS and PS fail to identify a significant proportion of avoidable deaths and miss important opportunities for process and system improvement. Based on this, all trauma deaths should be subjected to expert panel review in order to aim at a maximal output of performance improvement programs.     

Classification of adverse events occurring in a surgical intensive care unit

INTRODUCTION: We aimed to describe the preventability and provider specificity of surgical intensive care unit (SICU) deaths and complications compared with those in a cohort of trauma patients. METHODS: Data were collected on all trauma and SICU admissions from July 1, 2001, to June 30, 2004, from administrative (Trauma Base and Project Impact) and morbidity databases. Services were protocol driven and staffed by in-house attendings. Performance improvement assessments were made by consensus. Deaths and complications were classified as preventable, potentially preventable, or nonpreventable, and provider-specific or not. Statistical significance was established at the P < .05 level. RESULTS: One hundred sixty-eight deaths (5.6% rate), 464 procedure-related, and 694 non-procedure-related complications were noted in 2969 SICU patients compared with 166 deaths (3.6% rate), 178 procedure-related, and 261 non-procedure-related complications in 4,655 trauma patients. Thirty-one percent of SICU deaths were preventable/potentially preventable compared with 14% of trauma deaths, but only 1.9% was attributable to the SICU provider. SICU complications were less frequently preventable/potentially preventable than in trauma patients (52% versus 61%) and less often provider-specific (5% versus 19%). CONCLUSIONS: SICU complications are deemed preventable less often than in trauma patients and, if so, infrequently incriminate the SICU provider. Preventable and potentially preventable SICU deaths are rarely attributed to SICU care. These data suggest that SICU performance improvement should focus on systems solutions and pre-SICU 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.     

Utility of the international classification of diseases injury severity score: detecting preventable deaths and comparing the performance of emergency medical centers

OBJECTIVE: The purpose of this study was to assess the ability of the International Classification of Diseases-based Injury Severity Score (ICISS) to detect preventable deaths, and to compare the performance of trauma care facilities. METHODS: For 2 years, from 1997 to 1998, 131 trauma deaths and 1,087 blunt trauma inpatients from 6 emergency medical centers (EMCs) in Korea were reviewed. Trauma deaths were reviewed and the preventability of those deaths was judged by two professional panels. For both trauma deaths and trauma inpatients, the survival probability of each trauma patient was assessed using the ICISS full model. The degree of agreement in the preventability of trauma death between survival probability on the basis of the ICISS and judgment rendered by professional panels was determined, and the correlation between the W-score and the preventable death rate in each EMC was also assessed. RESULTS: The overall agreement rate between ICISS survival probability and preventable deaths judged by professional panels was 66.4% (kappa statistic, 0.36), and the positive predictive value of the ICISS in detecting preventable trauma deaths was 54.1% and the negative predictive value was 84.8%. The Spearman correlation coefficient between the W-score and the preventable death rate by each EMC was -0.77 (p = 0.07). CONCLUSION: The degree of agreement in the preventability of trauma death derived from the ICISS with a professional judgment on preventability was similar to that derived from the Trauma and Injury Severity Score. The W-scores of EMCs correlated well with their preventable death rates, with marginal statistical significance. This study has demonstrated that the ICISS is useful in detecting preventable deaths and in comparing the performance of trauma care facilities.     

Correlation of revised trauma score and injury severity score (TRISS) predicted probability of survival with peer-reviewed determination of trauma deaths

Trauma deaths at our institution are evaluated by a multidisciplinary trauma committee. The purpose of this study was to evaluate preventable trauma deaths (PRDs) as determined by our review committee and correlate them with the Revised Trauma Score and Injury Severity Score (TRISS) probability of survival (PS). A total of 10,002 patients were identified. The PS was calculated using the TRISS method. The Z scores were calculated and the predicted number of deaths was established. The actual number of deaths was compared with the predicted number of deaths. PRDs were compared with the actual and predicted deaths. The Z score was 0.79, which meant we observed more deaths than predicted by TRISS. We had 281 deaths compared with 271 deaths predicted by TRISS. Peer review characterized 45 deaths as preventable. Although we performed well when our outcomes were compared with TRISS predicted outcomes our PRD rate was higher. The higher the PS the more likely the death was found preventable by peer review. We conclude that for our patient population the peer review process is very sensitive and may be more discerning in identifying PRD than TRISS.     

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Background and objectivesDeaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery.MethodsWe examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model.ResultsOne hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively.ConclusionsA high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.     

THE MAJOR TRAUMA MANAGEMENT STUDY: AN ANALYSIS OF THE EFFICACY OF CURRENT TRAUMA CARE

Background : An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved. Methods : The Major Trauma Management Study (MTMS) collected data prospectively on all consecutively admitted major trauma patients at eight major hospitals during a 12-month period. Outcome was studied using trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT) analyses, as well as a preventable outcome analysis, which looked at survivors with complications or with a Glasgow Coma Score < 15 on discharge from hospital, as well as studying deaths. Results : The group of 859 patients was more severely injured than most described previously, with a mortality of 14.8% and a mean injury severity score of 19.8. Formal ASCOT analysis indicated 2.25% fewer survivors than would be predicted by Major Trauma Outcome Study norms. Extrapolating the TRISS and ASCOT process to include those patients with missing data, and then comparing groups of matched severity with the norms, gave no statistically different outcome in the MTMS group of patients. Preventable outcome analysis revealed rates of preventable and potentially preventable (P/PP) outcomes of 32% among deaths and 8% among survivors. The types of management deficiencies responsible for P/PP outcomes are identified. Conclusions : The points of deficiency in a system of care have been identified, and the development of an integrated trauma system in Victoria, based upon these facts, is recommended. Children, the elderly, patients with head injuries and patients being transferred between hospitals would benefit from improvements to the system of care. The calculation of efficacy rate (0.95 for the MTMS patients) is recommended to accurately assess the system of care. Preventable Outcome Analysis is more relevant to auditing a system of trauma care in detail, than is ASCOT or TRISS. The MTMS has refined and defined the process so that it is reproducible in further comparative studies.     

Are prehospital deaths from trauma and accidental injury preventable? A direct historical comparison to assess what has changed in two decades

Background & objectivesIn 1994, Hussain and Redmond revealed that up to 39% of prehospital deaths from accidental injury might have been preventable had basic first aid care been given. Since then there have been significant advances in trauma systems and care. The exclusion of prehospital deaths from the analysis of trauma registries, giv en the high rate of those, is a major limitation in prehospital research on preventable death. We have repeated the 1994 study to identify any changes over the years and potential developments to improve patient outcomes.MethodsWe examined the full Coroner’s inquest files for prehospital deaths from trauma and accidental injury over a three-year period in Cheshire. Injuries were scored using the Abbreviated-Injury-Scale (AIS-1990) and Injury Severity Score (ISS), and probability of survival estimated using Bull’s probits to match the original protocol.ResultsOne hundred and thirty-four deaths met our inclusion criteria; 79% were male, average age at death was 53.6 years. Sixty-two were found dead (FD), fifty-eight died at scene (DAS) and fourteen were dead on arrival at hospital (DOA). The predominant mechanism of injury was fall (39%). The median ISS was 29 with 58 deaths (43%) having probability of survival of >50%. Post-mortem evidence of head injury was present in 102 (76%) deaths. A bystander was on scene or present immediately after injury in 45% of cases and prior to the Emergency Medical Services (EMS) in 96%. In 93% of cases a bystander made the call for assistance, in those DAS or DOA, bystander intervention of any kind was 43%.ConclusionsThe number of potentially preventable prehospital deaths remains high and unchanged. First aid intervention of any kind is infrequent. There is a potentially missed window of opportunity for bystander intervention prior to the arrival of the ambulance service, with simple first-aid manoeuvres to open the airway, preventing hypoxic brain injury and cardiac arrest.     

Analysis of deaths due to injury in Milano: preliminary results

We reviewed all trauma deaths occurring in the urban area of Milan during one year. Autopsy reports were cross-referenced with pre- and in-hospital records and the Injury Severity Score was calculated by a senior surgeon. Causes of deaths were defined as central nervous system injury (CNS), hemorrhage (HEM), combined central nervous system injury and hemorrhage (CNS + HEM), and burns (BURN). Places of death were considered the scene (DOS), during transportation (DOA), the emergency room (DER), and hospital. Two multidisciplinary commissions reviewed patient reports and deaths were judged non-preventable, possibly preventable or frankly preventable, using the unanimous decision rule. The TRISS method was used to calculate the probability of survival for in-hospital deaths. Overall trauma deaths were 255 with 78.04% blunt and 16.08% penetrating traumas. Burns accounted for 5.88%. CNS and CNS + HEM caused 171 (67.05%) deaths. DOS were 91, DOA 48, DER 34, and in-hospital deaths 33. Victims found dead (49 individuals) were excluded from further analysis. The commissions classified 56.31% of deaths as non-preventable, 32.03% as possibly preventable and 11.65% as frankly preventable. The Injury Severity Score decreased from DOS to in-hospital deaths (p < 0.05). The preventability rate was higher for in-hospital deaths (p < 0.05). The results of this study suggest that the development of a tiered trauma system in Milan is mandatory.     

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.     

Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals

OBJECTIVE: The purpose of this study was estimate the number of preventable trauma deaths in teaching hospitals in Tehran. METHODS: We evaluated the complete prehospital, hospital, and postmortem data of 70 trauma patients who had died during a 1-year period in two of the largest university hospitals in Tehran with a multidisciplinary panel of experts. RESULTS: Panel members identified 26% of all trauma deaths as preventable deaths. From 31 non-central nervous system-related deaths, 17 and 6 cases were identified as surely preventable and probably preventable, respectively. In central nervous system-related deaths, 5% of the deaths overall (2 of 38 cases) were identified as surely preventable or probably preventable. Sixty-four cases of medical errors were identified in 31 trauma deaths and 80% of these errors were directly related to the death of the patients. CONCLUSION: The high preventable trauma death rate in our teaching hospitals indicates that a relatively significant percentage of trauma fatalities could have been prevented by improving prehospital and in-hospital trauma care.     

PREVENTABLE CAUSES OF DEATH AND DISABILITY FROM NEUROTRAUMA

Preventable causes of death and disability have been studied retrospectively in a series of 1161 cases of neurotrauma occurring in New South Wales in 1977–78, and prospectively in 153 cases of neurotrauma occurring in country districts in South Australia in 1981–82. In the first study, it was found that at least 80 deaths could be attributed to preventable causes; chiefly, transfer to an inappropriate hospital and/or delay in instituting treatment. Apparent failures in initial management of shock and airway obstruction were evident in this study and also in the South Australian study, which identified major deficiencies in cardiorespiratory management in 7% of cases transferred from country areas. These studies confirm that there is a need for better training, at all levels, in the management of neurotrauma. They also provide powerful arguments for the concept of an integrated regional trauma service.     

Minimizing Preventable Trauma Deaths in a Limited-Resource Setting: A Test-Case of a Multidisciplinary Panel Review Approach at the Komfo Anokye Teaching Hospital in Ghana

Objective

Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care.

Methods

A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006–2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified.

Results

The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %).

Conclusions

A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.     

Preventable complications and death from multiple organ failure among geriatric trauma victims.

We reviewed 374 consecutive trauma patients over age 65 years to determine (1) if the emergency room Trauma Score (TS) could predict mortality, thereby improving ICU triage, and (2) the frequency of preventable complications in patients who died (n = 31). Fifty-two percent of deaths (n = 16) occurred in patients with TS = 15 or 16. Multiple organ failure/sepsis (MOF/S) was the most common cause of death overall (42%) and was also the most frequent cause of death in patients with a TS = 15-16 (63%). Nonsurvivors in the TS = 15-16 subgroup were older (80.9 +/- 2.0 vs. 74.9 +/- 0.5 years, p less than 0.02) and had greater ISSs (15.8 +/- 3.7 vs. 8.0 +/- 0.4, p = 0.001) than survivors. Patients with a TS less than 15 suffered high overall mortality (45%). Preventable complications contributed to mortality in 32% of all deaths and in 62% of MOF/S deaths. Aggressive care to prevent avoidable complications may improve survival in elderly trauma victims.     

The effect of regionalization upon the quality of trauma care as assessed by concurrent audit before and after institution of a trauma system: a preliminary report

To assess the need for a trauma system in San Diego County, a concurrent audit of trauma care was performed by an independent consultant in 1982. During the study period from 15 March through 15 June 1982, 591 consecutive major trauma victims (MTV) were collected by the 30 participating hospitals. All medical records, including autopsy reports, were audited for the timeliness and appropriateness of diagnosis and definitive care. Deaths were classified as being not preventable, potentially salvageable, or preventable. A trauma system subsequently became functional on 1 August 1984, with five adult centers and one pediatric center. A Medical Audit Committee composed of physicians and nurses from designated and nondesignated hospitals was organized to perform a monthly concurrent audit of trauma care. Between 1 August and 31 December 1984, 1,366 MTV were triaged to trauma centers. The care of MTV was considered suboptimal in 32% of patients before regionalization, compared to 4.2% after regionalization (p less than 0.01). Preventable deaths occurred in 13.6% of fatalities occurring before implementation of a trauma system, compared to 2.7% after implementation (p less than 0.01). Regionalization of trauma care significantly reduced delays, inadequate care, and preventable deaths due to trauma.     

Impact of regionalization. The Orange County experience

Prior to the designation of a trauma system in Orange County, Calif, 73% of the in-hospital non-CNS deaths secondary to motor vehicular trauma were judged by the autopsy method to have been preventable. In June 1980, a regional system of trauma care with designated trauma centers was established in Orange County. We used the autopsy method to evaluate the first year's experience with this new system and compared the results with previous studies in Orange County for 1974, San Francisco County in 1974, and Orange County in 1978-1979. The results indicate a severe reduction in the number of deaths judged preventable. In addition, a more aggressive approach to the traumatized patient was noted as indicated by an increased percentage of patients who received appropriate surgical intervention.     

Preventable deaths and potentially preventable deaths. What are our errors?

BackgroundA variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem.ObjectivesDetect preventable and potentially preventable deaths, and classify all the errors with universal language.MethodsWe studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission.ResultsWe registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths.Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients.Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically ‘rule-based’ errorsConclusionsMeasuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.     

An autopsy study of traumatic deaths: San Diego County, 1979

All traumatic deaths in San Diego County were analyzed for the year of 1979. Death certificates, coroner's reports, and autopsy data served as the basis for this review. A total of 177 deaths were studied, of which 94 were associated with CNS injury and 83 were not. Sixteen (20 percent) of the deaths not CNS-associated and four (5 percent) of the CNS-associated deaths were classified as preventable. One hundred seventeen deaths were due to motor vehicle accidents, of which 11 of 35 (31 percent; all not CNS-associated) were deemed preventable. Preventable causes of death included hemorrhage, unrecognized hemopneumothorax, and unrecognized epidural hematoma.     

In-house trauma attendings: is there a difference?

INTRODUCTION: Outcomes of patients who met trauma activation criteria were examined before and after implementation of in-house attending call. MATERIALS AND METHODS: Outcomes for the out-of-house period (OH) (February 1, 2001 to October 31, 2002) were compared with the in-house period (IH) (November 1, 2002 to June 30, 2004). Measures included overall mortality, length of stay (LOS) in the hospital, intensive care unit (ICU) and emergency department, and preventable deaths. RESULTS: A total of 2,019 trauma activations were studied (1,036 OH, 983 IH). The groups were equivalent on admission. There was no difference in hospital LOS, ICU LOS, ventilator days, or overall mortality. Preventable deaths occurred in 8.1% of the OH group and in 1.0% of the IH group (P < .02). CONCLUSIONS: Aggregate statistics and the use of surrogate markers to determine outcomes may not accurately portray the impact of attending surgeons on the quality of care. Implementation of in-house call resulted in a decreased incidence of preventable deaths.