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Progress in surgical emergency care: Improvement in accuracy of diagnosis in a University Hospital in France
Progress in Surgical Emergency Care: Improvement in Accuracy of Diagnosis in a University Hospital in France
Jean E. Murat, MD, Tours, France N. Huten, MD, Tours, France
Progress in surgical emergency care is certainly related to complex life-saving procedures involving specialized teams; however, errors still occur during the initial clinical examination and may decrease the completeness or accuracy of initial assessment [l--2]. The basis for improvement in accuracy in the difficult field of multiple injuries is the acceptance of standardized procedures by the emergency staff [3]. We tested a method of standardized records in the emergency department of the University Hospital at Tours, which has the well-equipped facilities of a university hospital, well-trained personnel, and appropriate specialized teams who see 24,000 patients in the department every year. Material and Methods Since 1978, data regarding patients with two or more serious injuries, a blood pressure measurement lower than 90 mm Hg, or a hematocrit value below 27 percent have been recorded on a two page diagnostic checklist with 97 items. Results were used to audit our performance and as introductory research for entering of clinical items into a computer, as demonstrated by Gunn [4] in testing abdominal pain. In 1979 through 1980, a group of 115 patients met the requirement for inclusion. In 1981 through 1982,407 patients were studied [5]. This increase was due to the centralization and opening of a new emergency department in the university hospital. From 1982 to 1983, 382 patients were included [6]. Scores of the three groups are described in Table I according to the Abbreviated Injury Scale [7,8] but without scoring the initial figures as a means of simplication. From the Emergency Surgical Department, University Hospital, Tours, France. Requests for reprints should be addressed to Jean E. Murat, MD, Emergency Surgical Department, University Hospital, F-37044 Tours Cedex, France.
710
Resulta Diagnostic errors during the three periods are shown in Table II. Table III lists the missed diagnoses and shows an apparent improvement in diagnoses over time in chest and abdominal trauma and the remaining problems in diagnosis of less lifethreatening injuries (such as minor limb fractures) which are still missed, as in many other series [9]. Such missed diagnoses may be partly responsible for the morbidity rate caused by pulmonary complications [JO]. Despite the decrease in progress of the third and more recent group, the increase in the number of patients with abbreviated injury scores over 15 is still significantly higher than in the first group (p < 0.001). The significant decrease in mortality between the first two groups (33 percent to 20.6 percent; p > 0.001) stabilized in the third group (20.6 percent and 22 percent, respectively) (Table IV). Comments
The favorable experience in improvement of outof-hospital resuscitation, along with the improvement of in-hospital care by the use of standardized assessment procedures [11], has maintained efficient management of the emergency department and helps to improve accuracy of diagnosis in polytrauma patients by use of a routine framework for systematic clinical examination. Using the form as a checklist ensures standardization of basic requirements and may be extended by use of a computer system, as in diagnoses in other areas, not for computerized diagnosis but as an aid for immediate efficiency. Such an aid gives an easy, standard, and transferrable record that follows the patient to oth-
The American Journal of Surgery
Salute to Robert M.
TABLE I
Injury Scores 15 10-14 5-9 4
Abbreviated injury Scores Durlng the Three Study Periods 1979-1980 (rl = 115) -% n 11 50 50 4
1981-1982 (n = 407) n %
10.4 43.5 43.5 3.5
110 150 137 10
27.1’ 36.9 33.6 2.4
1982-1983 (n = 382) n % 107 148 114 13
28.1+ 38.7 29.8 3.4
. p
TABLE II
Area Abdomen Chest Fractures Total
Abdomen Ruptured spleen Liver and pancreatic injulry Mesenteric bleeding Chest Pulmonary damage Ruptured diaphragm Aortic: rupture Myocardial damage Fractures Limbs Spine Pelvis
1981-1982 n %
1983-1984 n %
6 2
5.2 1.7
5 3
1.2 0.7
4 3
1 0.8
1
0.9
1
0.2
1
0.3
4 3 2 2
3.4 2.6 1.7 1.7
3 3 1 3
0.7 0.7 0.2 0.7
3 2 1 3
0.8 0.5 0.3 0.8
4 2 1
3.5 1.7 0.9
10 2 2
2.5 0.5 0.5
9 1 2
2.3 0.3 0.5
Summary The accuracy of diagnosis in multiple trauma can be greatly improved by the use of standardized assessment routines and uniform documentation. In the three groups of patients reviewed, the diagnostic error rate decreased from 23 percent in 1979 to 1980 to 8 percent in 1981to 1982, and decreased further
151,
June
1988
1981-1982 % n
1983-1984 % n
8 9 6
9 11 7
2 2.5 3.5
9 10 14
2.1 2.4 3.1
8 9 12
23
27
8
33’
7.6
29+
period.
Mortality and Morbidity Rates 1979-1980 % n
er departments. This information may be used not only medically but also in cost evaluation. These databases must be developed for accurate medical audits and for teaching the junior staff (who are on 6 month rotations) so that appropriate action and better follow-up, from the initial management to final outcome of the patient, is possible. However, such a routine is not always well accepted by all staff members, despite objective improvements. This is demonstrated by our most recent results, which show that a margin of error still persists and results in a delay of appropriate action. We must bear in mind the primary goal of standardized assessment routines in the difficult area of emergency medical practice. Both treatment of patients and cost containment are improved by such routines.
Volume
1979-1980 % n
period
TABLE 111 Missed Lesions and Their Incidence 1979-1980 n %
Errors In Dlagnosls In Major Anatomlc Areas
* p
TABLE IV
Site
MD
Zollinger,
Mortality Morbidity
33 25.2
38 29
1981-1982 % n --20.6 30
84’ 122
’ p
1983-1984 % n 22 27
84+ 103
period.
to 7.6 percent in 1983 to 1984. Our latest results show that a margin of error still persists. We believe that standardization of assessment routines in the difficult area of emergency medical practice is in the patient’s best interest. References 1. Murat JE, Huten N, Bernard JL, Vaur JL. Organization des urgences en chirurgie generale et digestive. In: Les urgences en chirurgie digestive et generale Paris: Masson, 1980. 2. Murat JE. Vaur JL, Bernard JL. Pasdeloup J. Guidelines for a hospital emergency medical department in a university hospital in France. A progress report. Am J Surg 1980; 139:240-3. 3. Gilroy D. Deaths from blunt trauma. A review of 105 cases. Injury 1984;15:304-8. 4. Gunn AA. The diagnosis of acute abdominal pain with computer analysis. J R Coil Surg Edinb 1976;21:170-2. 5. Maillet ML. Abord et reanimation des polytraumatises. Experience d’un an a Tours. Academic dissertation, University of Tours, 1980. 6. Murat JE, Huten N. Enseigner et controller les soins d’urgence: approche d’analyse globale. Bull Natl Acad Med 1985;l: 1:88-94. 7. Baker SP, O’Neil B, Haddon W, Long WB. The injury severity score: a method for describing the patient with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-96. 8. Champion HR, Sacco WJ, Hunt TK. Trauma severity scoring to predict mortality. World J Surg 1983;7:4- 11. 9. McLaren CAN, Robertson C, Little K. Missed or-thopaedic injuries in the resuscitation room. J R Coil Surg Edinb 1983;28:399-401. 10. Jansen I, Erikson R, Leljedaik SD. Primary fracture immobilization as a method to prevent posttraumatic pulmonary changes in the experimental model. Acta Chir Stand 1982;148:329-38. 11. Murat JE, Huten N. Mesny J. The use oi a standardized assessment procedure in the evaluation of patients with multiple injuries. Arch Emerg Med 1985;2:11-5.
711
Jean E. Murat, MD, Tours, France N. Huten, MD, Tours, France
Progress in surgical emergency care is certainly related to complex life-saving procedures involving specialized teams; however, errors still occur during the initial clinical examination and may decrease the completeness or accuracy of initial assessment [l--2]. The basis for improvement in accuracy in the difficult field of multiple injuries is the acceptance of standardized procedures by the emergency staff [3]. We tested a method of standardized records in the emergency department of the University Hospital at Tours, which has the well-equipped facilities of a university hospital, well-trained personnel, and appropriate specialized teams who see 24,000 patients in the department every year. Material and Methods Since 1978, data regarding patients with two or more serious injuries, a blood pressure measurement lower than 90 mm Hg, or a hematocrit value below 27 percent have been recorded on a two page diagnostic checklist with 97 items. Results were used to audit our performance and as introductory research for entering of clinical items into a computer, as demonstrated by Gunn [4] in testing abdominal pain. In 1979 through 1980, a group of 115 patients met the requirement for inclusion. In 1981 through 1982,407 patients were studied [5]. This increase was due to the centralization and opening of a new emergency department in the university hospital. From 1982 to 1983, 382 patients were included [6]. Scores of the three groups are described in Table I according to the Abbreviated Injury Scale [7,8] but without scoring the initial figures as a means of simplication. From the Emergency Surgical Department, University Hospital, Tours, France. Requests for reprints should be addressed to Jean E. Murat, MD, Emergency Surgical Department, University Hospital, F-37044 Tours Cedex, France.
710
Resulta Diagnostic errors during the three periods are shown in Table II. Table III lists the missed diagnoses and shows an apparent improvement in diagnoses over time in chest and abdominal trauma and the remaining problems in diagnosis of less lifethreatening injuries (such as minor limb fractures) which are still missed, as in many other series [9]. Such missed diagnoses may be partly responsible for the morbidity rate caused by pulmonary complications [JO]. Despite the decrease in progress of the third and more recent group, the increase in the number of patients with abbreviated injury scores over 15 is still significantly higher than in the first group (p < 0.001). The significant decrease in mortality between the first two groups (33 percent to 20.6 percent; p > 0.001) stabilized in the third group (20.6 percent and 22 percent, respectively) (Table IV). Comments
The favorable experience in improvement of outof-hospital resuscitation, along with the improvement of in-hospital care by the use of standardized assessment procedures [11], has maintained efficient management of the emergency department and helps to improve accuracy of diagnosis in polytrauma patients by use of a routine framework for systematic clinical examination. Using the form as a checklist ensures standardization of basic requirements and may be extended by use of a computer system, as in diagnoses in other areas, not for computerized diagnosis but as an aid for immediate efficiency. Such an aid gives an easy, standard, and transferrable record that follows the patient to oth-
The American Journal of Surgery
Salute to Robert M.
TABLE I
Injury Scores 15 10-14 5-9 4
Abbreviated injury Scores Durlng the Three Study Periods 1979-1980 (rl = 115) -% n 11 50 50 4
1981-1982 (n = 407) n %
10.4 43.5 43.5 3.5
110 150 137 10
27.1’ 36.9 33.6 2.4
1982-1983 (n = 382) n % 107 148 114 13
28.1+ 38.7 29.8 3.4
. p
TABLE II
Area Abdomen Chest Fractures Total
Abdomen Ruptured spleen Liver and pancreatic injulry Mesenteric bleeding Chest Pulmonary damage Ruptured diaphragm Aortic: rupture Myocardial damage Fractures Limbs Spine Pelvis
1981-1982 n %
1983-1984 n %
6 2
5.2 1.7
5 3
1.2 0.7
4 3
1 0.8
1
0.9
1
0.2
1
0.3
4 3 2 2
3.4 2.6 1.7 1.7
3 3 1 3
0.7 0.7 0.2 0.7
3 2 1 3
0.8 0.5 0.3 0.8
4 2 1
3.5 1.7 0.9
10 2 2
2.5 0.5 0.5
9 1 2
2.3 0.3 0.5
Summary The accuracy of diagnosis in multiple trauma can be greatly improved by the use of standardized assessment routines and uniform documentation. In the three groups of patients reviewed, the diagnostic error rate decreased from 23 percent in 1979 to 1980 to 8 percent in 1981to 1982, and decreased further
151,
June
1988
1981-1982 % n
1983-1984 % n
8 9 6
9 11 7
2 2.5 3.5
9 10 14
2.1 2.4 3.1
8 9 12
23
27
8
33’
7.6
29+
period.
Mortality and Morbidity Rates 1979-1980 % n
er departments. This information may be used not only medically but also in cost evaluation. These databases must be developed for accurate medical audits and for teaching the junior staff (who are on 6 month rotations) so that appropriate action and better follow-up, from the initial management to final outcome of the patient, is possible. However, such a routine is not always well accepted by all staff members, despite objective improvements. This is demonstrated by our most recent results, which show that a margin of error still persists and results in a delay of appropriate action. We must bear in mind the primary goal of standardized assessment routines in the difficult area of emergency medical practice. Both treatment of patients and cost containment are improved by such routines.
Volume
1979-1980 % n
period
TABLE 111 Missed Lesions and Their Incidence 1979-1980 n %
Errors In Dlagnosls In Major Anatomlc Areas
* p
TABLE IV
Site
MD
Zollinger,
Mortality Morbidity
33 25.2
38 29
1981-1982 % n --20.6 30
84’ 122
’ p
1983-1984 % n 22 27
84+ 103
period.
to 7.6 percent in 1983 to 1984. Our latest results show that a margin of error still persists. We believe that standardization of assessment routines in the difficult area of emergency medical practice is in the patient’s best interest. References 1. Murat JE, Huten N, Bernard JL, Vaur JL. Organization des urgences en chirurgie generale et digestive. In: Les urgences en chirurgie digestive et generale Paris: Masson, 1980. 2. Murat JE. Vaur JL, Bernard JL. Pasdeloup J. Guidelines for a hospital emergency medical department in a university hospital in France. A progress report. Am J Surg 1980; 139:240-3. 3. Gilroy D. Deaths from blunt trauma. A review of 105 cases. Injury 1984;15:304-8. 4. Gunn AA. The diagnosis of acute abdominal pain with computer analysis. J R Coil Surg Edinb 1976;21:170-2. 5. Maillet ML. Abord et reanimation des polytraumatises. Experience d’un an a Tours. Academic dissertation, University of Tours, 1980. 6. Murat JE, Huten N. Enseigner et controller les soins d’urgence: approche d’analyse globale. Bull Natl Acad Med 1985;l: 1:88-94. 7. Baker SP, O’Neil B, Haddon W, Long WB. The injury severity score: a method for describing the patient with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187-96. 8. Champion HR, Sacco WJ, Hunt TK. Trauma severity scoring to predict mortality. World J Surg 1983;7:4- 11. 9. McLaren CAN, Robertson C, Little K. Missed or-thopaedic injuries in the resuscitation room. J R Coil Surg Edinb 1983;28:399-401. 10. Jansen I, Erikson R, Leljedaik SD. Primary fracture immobilization as a method to prevent posttraumatic pulmonary changes in the experimental model. Acta Chir Stand 1982;148:329-38. 11. Murat JE, Huten N. Mesny J. The use oi a standardized assessment procedure in the evaluation of patients with multiple injuries. Arch Emerg Med 1985;2:11-5.
711