- Email: [email protected]
System care improves trauma outcome: Patient care errors dominate reduced preventable death rate
The Journal
of Emergency
Medicine,
Vol 11, pp 135-I 39, 1993
Prlnted in the USA
CopyrIght
0 1993 Pergamon
Press Ltd.
SYSTEM CARE IMPROVES TRAUMA OUTCOME: PATIENT CARE ERRORS DOMINATEREDUCEDPREVENTABLEDEATHRATE E. Thoburn,
MD,* P. Norris, RN,* R. Flares, as,* S. Goode, RN,* E. Rodriguez, S. Campbell, MD, FACS,t M. Albrink, MD,** and A. Rosemurgy, MD, tliillsborough
Reprint
Address:
Michael
Trauma Agency; ‘The Department of Surgery, University of South Florida; and *The Tampa General Hospital, Tampa, Florida H. Albrink MD, Harbourside Medical Tower, Suite 730, 4 Columbia Drive, Tampa, FL 33606
trauma
Hillsborough County, Florida, identifying 14 (23%) as preventable (4). In response to this, in late 1988 Hillsborough County organized the Hillsborough County Trauma Agency (HCTA) to coordinate trauma care among prehospital care providers and state designated trauma centers. There were numerous other changes in trauma systems on local, regional, and state levels. The HCTA, in conjunction with prehospital care providers and state designated trauma centers, developed triage criteria and indepth quality assurance programs in order to improve trauma care in Hillsborough County. The purpose of this study is to evaluate the effect an organized trauma system has had on the preventable death rate in Hillsborough County, Florida, and to evaluate deficiencies in this system. METHODS
systems; preventable
Hillsborough County, Florida, has a population of 852,000, with a mix of urban, suburban, and some rural areas. It is served by a two-tiered EMS system with both Basic Life Support (BLS) and Advanced Life Support (ALS) units activated by 911. Three are two ALS providers, both with professional staffing by EMT-Ps and close medical command. By protocol, all trauma patients are transported by ALS units to designated trauma centers (one Level I and two Level 11s). There are two hospital-based aeromedical rescue programs, and each has similar crew makeup (one pilot, one EMT-P, one RN) per flight. Each aeromedical program has careful medical control, and each interacts cohesively with all ground systems.
INTRODUCTION Trauma is the leading cause of death in persons between the ages of 1 and 39 years in this country (1). It has been estimated that trauma accounts for 100,000 to 160,000 deaths each year, and for each mortality, two patients are permanently disabled (2,3). In the past decade, several studies have documented 20% to 73% preventable trauma death rates, prior to the development of regionalized trauma care (2-6). In 1988, Campbell et al. presented a review of 62 non-CNS trauma deaths occurring during 1984 in RECEIVED: ACCEPTED:
V. Adams, MD,t
FAcs*t*
County
0 Abstract-A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hlllsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. Results: SO4trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, S preventable deaths occurred late in severely injured patients. Conclusion: The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors. q Keywords-trauma; trauma deaths
MD,+
5 February 1992; FINAL SUBMISSION RECEIVED: 21 August 1992 135
3 August 1992;
0736-4679193 $6.00 + .OO
136
E. Thoburn
Prior to 1985, a much less detailed system was in place. There were no destination protocols and very few trauma transport protocols. Seriously injured patients would be transported to the nearest facility regardless of that facility’s capabilities. The trauma centers were self-designated and had little scrutiny or quality assurance. Prior to 1985, immediate availability of a trauma surgeon was not a priority; the concept of a “trauma alert,” prehospital institution of an accelerated team response, was introduced in 1985. All trauma deaths in Hillsborough County, Florida, occurring between October 1, 1989, and April 30, 1991, were reviewed. Deaths due to isolated central nervous system injuries, drowning, and thermal injuries were excluded in a manner similar to that described by Campbell (4) to ensure an appropriate comparison with the previous study. Five hundred and four trauma deaths were then reviewed in detail. Of these fatalities, 272 (54%) were pronounced dead at the scene of injury (by local EMS protocol) and were not transported to a health care facility. The remaining 232 (460/o) fatalities were transported for definitive care. A committee consisting of three trauma surgeons, three medical examiners, one senior level surgical resident, two trauma coordinators, and two paramedics was assembled to determine whether patients transported to a health care facility who died had preventable or nonpreventable deaths. Records of prehospital care and hospital care (including emergency department, operating room, ICU, and post-ICU care), as well as medical examiners’ autopsy reports on all 232 patients were scrutinized. Each trauma center supplied trauma registry data with Trauma Base@ (Data Management Inc., Denver, CO) software used in all three centers as well as in the Hillsborough County Trauma Agency. Attention was paid to prehospital response time, transport time, physician response time, and resuscitation measures, as well as to operative intervention, invasive procedures, and postresuscitation care. Injury Severity Scores (ISS) were determined by review of medical examiners’ records (based on AIS ‘85 criteria) [7]. A determination of accuracy of each record was made by comparison and correlation of all available data from each source.
Table 2. Nonpreventable
et al.
Deaths Total
222
Male Female Blunt Penetrating Avg Age (Range i-68) Avg ISS
151 71 161 61 40 43.5
Designation of “nonpreventable” or “preventable” was assigned to each death by committee consensus, either unanimous or majority. Preventable deaths were defined as those deaths in which serious injuries (AIS ‘85 1 3) or occurrences were missed or were inappropriately or inadequately treated, and in which these same missed or inappropriately treated injuries were deemed directly causal of the death.
RESULTS During the 18-month period from October 1, 1989, to April 30, 1991, 504 fatalities occurred in Hillsborough County due to trauma, excluding those caused by isolated central nervous system injury, drowning, and thermal injuries. Upon review of the 504 fatalities, 272 (54%) were found to have been declared dead at the scene of injury (by EMS protocols) and were not transported to a health care facility. Of the remaining 232 deaths, 143 (62%) had undergone cardiopulmonary resuscitation (CPR) prior to arrival at the emergency department, while the remaining 89 (38%) arrived without prior CPR. The 232 patients who were transported for definitive care underwent extensive committee review. Ten patients were felt to have died preventable or potentially preventable deaths. The remaining 222 patients were felt to have suffered lethal injuries (Table 1). Of the 222 nonpreventable deaths, there were 151 men and 71 women, ranging in age from 1 to 88 years, with an average age of 40 years. Blunt trauma accounted for 161 deaths, while penetrating injuries accounted for 61 deaths. The average ISS was 43.5 Table 3. Injuries Deaths
by Body Region
in 222 Nonpreventable
Table 1. Trauma deaths Total Scene Transported with CPR without CPR Preventable
504 272 232 143 89 10
Thorax Head/Face AbdlPelvic contents Extremities/Pelvic girdle
162 143 117 90 36 35
Spine External Total
597
137
System Care Improves Outcome Table
4. Causes
of 222 Nonpreventable
Deaths
Hemorrhage CNS Sepsis Respiratory Cardiac
110 63 11 11 7 Total
222
(Table 2). A total of 597 serious injuries were noted, for an average of 2.7 serious injuries per fatality. The most common serious injuries involved the chest (162), head (143), and abdomen (117) (Table 3). Nonpreventable death was most commonly due to hemorrhage, head or spine injury, or cardiorespiratory injury (Table 4). Half of all nonpreventable deaths were due to hemorrhage. In the 10 patients who were felt to have suffered preventable or potentially preventable deaths, 7 were men and 3 were women. The average 1% was 25.8, with a range of 9 to 44. The average age was 47 years, with a range of 26 to 84 years. Seven injuries were related to blunt trauma; three were related to penetrating trauma. Death was most commonly due to exsanguination. Two patients died because of missed aortic injuries leading to exsanguinating hemorrhage, and three died because of ongoing hemorrhage with inadequate fluid resuscitation. Three patients died late in their care, 9 to 20 days after admission, from aspiration of gastric contents with subsequent respiratory arrest. While it is conceivable that none of these 3 aspiration deaths was preventable, our committee deemed them potentially preventable to ensure the absence of bias. One patient died 23 days after admission due to complications of previously unrecognized sepsis. This patient was monitored in the ICU and was noted to be developing progressive respiratory failure with associated hemodynamic instability. Despite early recognition by the nursing staff, the patient was not evaluated by a physician until he suffered a respiratory arrest requiring emergency intubation. He subsequently died because of an anoxic brain injury. Another patient died of a pulmonary embolus 5 days after admission with a grade IIIB femur fracture. No deep venous thrombosis (DVT) prophylaxis was administered (Table 5). It is Table
5. Preventable
Major
Injury
Transected pancreas Multi fx CHI GSW abd Femur fx GSW abd
Trauma
standard protocol to administer some form of DVT prophylaxis (minidose heparin, low-dose Warfarin, or sequential compression stockings in some combination) at each of the institutions. It is possible that this complication is not preventable, yet our committee considered it potentially preventable to ensure the absence of bias. Two of the patients who suffered preventable or potentially preventable deaths were cared for outside the Hillsborough County Trauma System. One patient suffered a gun shot wound (GSW) to the abdomen and was transported by private vehicle to a local hospital (not a trauma center) where she underwent celiotomy and later died of an aortic injury missed at exploration. While it is unusual for a gun shot wound of the aorta to be preventable, this patient presented with a stable blood pressure, and she had an unacceptable delay in time to surgery (1 hour 35 minutes). This same patient survived for several hours after her initial operation with the missed injury. In determining the preventable death rate, we eliminated the 272 scene fatalities. Scene fatalities are determined by protocol if rigor mortis is present, with decapitation, open head injury with arrest, or significant trauma history with total absence of vital signs and asystole. Of the 232 patients transported to hospitals, 4.3% (10/232) suffered preventable or possibly preventable deaths. If it is argued that the 143 patients who arrived at the emergency department undergoing CPR did not have a significant chance for survival, the preventable death rate would be 11.2% (10/89). It is highly likely that the current study overestimates the preventable death rate, particularly by including the 3 late deaths from gastric aspiration and the missed aortic injury cared for outside of the county trauma system. If these 4 deaths are excluded, the preventable death rate would be 7.0% (6/85). DISCUSSION
In 1966 the National Research Council’s Committee on Trauma and Committee on Shock labeled trauma “the neglected disease of modern society” (8). This designation was supported by several studies, the first by Von Wagoner (9) in 1961 showing a 33%
Deaths Age
Sex
ISS
27 35 26 35 26
M M F M M
25 44 34 9 25
Cause
of Death
Sepsis Gastric aspiration Aortic injury Pulmon. embolus Gastric aspiration
Comments Delay in Rx Arch bars Missed injury No DVT prophylaxis Aspirated during placement
of NG
138
E. Thoburn
preventable death rate. In 1986 the American College of Surgeons’ Committee on Trauma (8) developed criteria for the establishment of trauma systems and the designation of trauma centers. A study by West in 1988 (8) showed that only 2 states out of the 50 states, and the District of Columbia, had the essential components of a regionalized trauma system. The state of Florida passed its first trauma legislation in 1982, which required all hospitals seeking trauma center designation to be verified by the Department of Health and Rehabilitative Services (HRS) as meeting state guidelines. This legislation was then expanded in 1987, requiring HRS to develop a statewide trauma system (10). Prior to 1987 legislation, the preventable trauma death rate in Hillsborough County was found to be 22.6% of non-CNS deaths (4). Hillsborough County developed an organized trauma system in late 1988 that includes prehospital advanced life support capabilities, a transportation system with both ground and air transport, a communication network, designated trauma centers, and a county-wide trauma registry. Since the inception of the Hillsborough County trauma system there has been a significant decrease in preventable fatalities within the system, to 7.0% (6/85). This preventable death rate excludes all trauma patients who received CPR either in transport or at the scene. This exclusion is based on the assumption that there is no chance for survival in these patients. Traumatic cardiac arrest from blunt injury has almost uniform fatality, and cardiac arrest from penetrating injury has very high fatality rates. While others have stated (11) that 20% of patients who arrive at trauma centers classified as “dead on arrival” can be resuscitated and thereby survive, we believe that these data are both antiquated and hyperbole. We believe that a preventable death rate of 7% represents a reasonable application and interpretation of these data, as well as a significant improvement over the prior report from the same area. The small number of trauma centers (n = 3), prehospital advanced life support care systems (n = 2), and aeromedical advanced life support systems (n = 2), as well as the accurately detailed records and 100% autopsy availability, have allowed an in-depth review of our current system. In 1984, 78% of preventable deaths were due to system problems, most
et al.
notably, a delay in surgery. Cales (5) studied the effect of a regional trauma system in Orange County, California, and found a similar incidence (70%) of preventable deaths due to system problems prior to the development of a trauma system. Trauma systems have been proven to significantly reduce preventable deaths. Recently, evaluations of these deaths (12-24) have shown a change from system errors, as seen in cases of delayed or inadequate intervention, to errors in postoperative care. Currently, preventable deaths are generally (50%) late deaths or deaths due to errors in postoperative care. Davis and colleagues (12) studying the significance of treatment errors in trauma patients within a trauma system, found a similar (48%) preventable death rate caused by errors in postoperative care. To continue to improve care within County Trauma Systems, mechanisms should be established within the trauma systems to identify causes of preventable death through evaluation of prehospital, hospital, and medical examiners’ records. Trauma care providers, including paramedics, nurses, and physicians, should be educated in the causes of preventable deaths, including postoperative or postresuscitation care errors. Protocols should be developed to address the causes of preventable death. For example, defining parameters of the extent of exploration of body cavities (for example, opening the lesser sac to fully visualize the entire pancreas) and ensuring appropriate review of admission radiographic studies could further decrease missed injuries. Finally, establishing and enforcing nursing protocols that ensure communications with physicians and provide for appropriate care of common, but nonetheless potentially life-threatening situations, will diminish the occurrence of postoperative or postresuscitation care errors. With these enhancements, preventable death rates should continue to decrease, although they may never each zero. Most importantly, the total number of preventable deaths can be decreased through the reduction of overall trauma deaths. Prevention programs and public education should stress the dangers of drinking and driving, the importance of airbags, seatbelts, and helmet use, the relationships between violent crime and illegal drugs, and finally, the importance of utilizing an established trauma system in treating seriously injured persons.
REFERENCES 1. Hammond J, Gomez G, Eckes J. Trauma systems economic and political considerations. J Florida M. A. 1990;77:603-5. 2. Kreis DJ Jr, Plasencia G, Augenstein D, et al. Preventable
trauma deaths: Dade County, Florida. J Trauma. 1986;26: 649-54. 3.Lowe DK, Gately HL, Goss JR, et al. Patterns of death, com-
System Care Improves Outcome
4. 5. 6. 7. 8. 9.
plications, and errors in the management of motor vehicle accident victims: implications for a regional system of trauma care. J Trauma. 1983;23:503-9. Campbell S, Watkins G, Kreis D. Preventable deaths in a self-designated trauma system. Am Surg. 1989;55:478-80. Cales RH. Trauma mortality in Orange County: the effect of implementation of a regional trauma system. Ann Emerg Med. 1984;13:1-10. West JG, Trunkey DD, Lim RC. Systems of trauma care: a study of two counties. Arch Surg. 1979; 114:45S-60. The Abbreviated Injury Severity Scale 1985 revision. American Association for Automotive Medicine. Des Plaines, Illinois. West JG, Williams MJ, Trunkey DD, Wolferth CC. Trauma systems current status-future challenges. JAMA. 1988;259: 3597-600. Von Wagner FH. Died in hospital: a three year study of deaths following trauma. J Trauma. 1961;1:401-8.
139 10. State of Florida Department of Health and Rehabilitative Services. A report and proposal for funding state-sponsored trauma centers. 1990. 11. Trunkey DD. Trauma. Scientific American. 1983;249(2):2835. 12. Davis JW, Hoyt DB, McArdle MS, et al. The significance of critical care errors in causing preventable death in trauma patients in a trauma system. J Trauma. 1991;31:813-9. 13. Guss DA, Meyer FT, Neuman TS, et al. The impact of a regionalized trauma system on trauma care in San Diego County. Ann Emerg Med. 1989;18:1141-5. 14. Shackford JR, Hollingworth-Fridlund P, Cooper GF, Eastman AB. 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. J Trauma. 1986;26:812-20.
of Emergency
Medicine,
Vol 11, pp 135-I 39, 1993
Prlnted in the USA
CopyrIght
0 1993 Pergamon
Press Ltd.
SYSTEM CARE IMPROVES TRAUMA OUTCOME: PATIENT CARE ERRORS DOMINATEREDUCEDPREVENTABLEDEATHRATE E. Thoburn,
MD,* P. Norris, RN,* R. Flares, as,* S. Goode, RN,* E. Rodriguez, S. Campbell, MD, FACS,t M. Albrink, MD,** and A. Rosemurgy, MD, tliillsborough
Reprint
Address:
Michael
Trauma Agency; ‘The Department of Surgery, University of South Florida; and *The Tampa General Hospital, Tampa, Florida H. Albrink MD, Harbourside Medical Tower, Suite 730, 4 Columbia Drive, Tampa, FL 33606
trauma
Hillsborough County, Florida, identifying 14 (23%) as preventable (4). In response to this, in late 1988 Hillsborough County organized the Hillsborough County Trauma Agency (HCTA) to coordinate trauma care among prehospital care providers and state designated trauma centers. There were numerous other changes in trauma systems on local, regional, and state levels. The HCTA, in conjunction with prehospital care providers and state designated trauma centers, developed triage criteria and indepth quality assurance programs in order to improve trauma care in Hillsborough County. The purpose of this study is to evaluate the effect an organized trauma system has had on the preventable death rate in Hillsborough County, Florida, and to evaluate deficiencies in this system. METHODS
systems; preventable
Hillsborough County, Florida, has a population of 852,000, with a mix of urban, suburban, and some rural areas. It is served by a two-tiered EMS system with both Basic Life Support (BLS) and Advanced Life Support (ALS) units activated by 911. Three are two ALS providers, both with professional staffing by EMT-Ps and close medical command. By protocol, all trauma patients are transported by ALS units to designated trauma centers (one Level I and two Level 11s). There are two hospital-based aeromedical rescue programs, and each has similar crew makeup (one pilot, one EMT-P, one RN) per flight. Each aeromedical program has careful medical control, and each interacts cohesively with all ground systems.
INTRODUCTION Trauma is the leading cause of death in persons between the ages of 1 and 39 years in this country (1). It has been estimated that trauma accounts for 100,000 to 160,000 deaths each year, and for each mortality, two patients are permanently disabled (2,3). In the past decade, several studies have documented 20% to 73% preventable trauma death rates, prior to the development of regionalized trauma care (2-6). In 1988, Campbell et al. presented a review of 62 non-CNS trauma deaths occurring during 1984 in RECEIVED: ACCEPTED:
V. Adams, MD,t
FAcs*t*
County
0 Abstract-A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hlllsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. Results: SO4trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, S preventable deaths occurred late in severely injured patients. Conclusion: The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors. q Keywords-trauma; trauma deaths
MD,+
5 February 1992; FINAL SUBMISSION RECEIVED: 21 August 1992 135
3 August 1992;
0736-4679193 $6.00 + .OO
136
E. Thoburn
Prior to 1985, a much less detailed system was in place. There were no destination protocols and very few trauma transport protocols. Seriously injured patients would be transported to the nearest facility regardless of that facility’s capabilities. The trauma centers were self-designated and had little scrutiny or quality assurance. Prior to 1985, immediate availability of a trauma surgeon was not a priority; the concept of a “trauma alert,” prehospital institution of an accelerated team response, was introduced in 1985. All trauma deaths in Hillsborough County, Florida, occurring between October 1, 1989, and April 30, 1991, were reviewed. Deaths due to isolated central nervous system injuries, drowning, and thermal injuries were excluded in a manner similar to that described by Campbell (4) to ensure an appropriate comparison with the previous study. Five hundred and four trauma deaths were then reviewed in detail. Of these fatalities, 272 (54%) were pronounced dead at the scene of injury (by local EMS protocol) and were not transported to a health care facility. The remaining 232 (460/o) fatalities were transported for definitive care. A committee consisting of three trauma surgeons, three medical examiners, one senior level surgical resident, two trauma coordinators, and two paramedics was assembled to determine whether patients transported to a health care facility who died had preventable or nonpreventable deaths. Records of prehospital care and hospital care (including emergency department, operating room, ICU, and post-ICU care), as well as medical examiners’ autopsy reports on all 232 patients were scrutinized. Each trauma center supplied trauma registry data with Trauma Base@ (Data Management Inc., Denver, CO) software used in all three centers as well as in the Hillsborough County Trauma Agency. Attention was paid to prehospital response time, transport time, physician response time, and resuscitation measures, as well as to operative intervention, invasive procedures, and postresuscitation care. Injury Severity Scores (ISS) were determined by review of medical examiners’ records (based on AIS ‘85 criteria) [7]. A determination of accuracy of each record was made by comparison and correlation of all available data from each source.
Table 2. Nonpreventable
et al.
Deaths Total
222
Male Female Blunt Penetrating Avg Age (Range i-68) Avg ISS
151 71 161 61 40 43.5
Designation of “nonpreventable” or “preventable” was assigned to each death by committee consensus, either unanimous or majority. Preventable deaths were defined as those deaths in which serious injuries (AIS ‘85 1 3) or occurrences were missed or were inappropriately or inadequately treated, and in which these same missed or inappropriately treated injuries were deemed directly causal of the death.
RESULTS During the 18-month period from October 1, 1989, to April 30, 1991, 504 fatalities occurred in Hillsborough County due to trauma, excluding those caused by isolated central nervous system injury, drowning, and thermal injuries. Upon review of the 504 fatalities, 272 (54%) were found to have been declared dead at the scene of injury (by EMS protocols) and were not transported to a health care facility. Of the remaining 232 deaths, 143 (62%) had undergone cardiopulmonary resuscitation (CPR) prior to arrival at the emergency department, while the remaining 89 (38%) arrived without prior CPR. The 232 patients who were transported for definitive care underwent extensive committee review. Ten patients were felt to have died preventable or potentially preventable deaths. The remaining 222 patients were felt to have suffered lethal injuries (Table 1). Of the 222 nonpreventable deaths, there were 151 men and 71 women, ranging in age from 1 to 88 years, with an average age of 40 years. Blunt trauma accounted for 161 deaths, while penetrating injuries accounted for 61 deaths. The average ISS was 43.5 Table 3. Injuries Deaths
by Body Region
in 222 Nonpreventable
Table 1. Trauma deaths Total Scene Transported with CPR without CPR Preventable
504 272 232 143 89 10
Thorax Head/Face AbdlPelvic contents Extremities/Pelvic girdle
162 143 117 90 36 35
Spine External Total
597
137
System Care Improves Outcome Table
4. Causes
of 222 Nonpreventable
Deaths
Hemorrhage CNS Sepsis Respiratory Cardiac
110 63 11 11 7 Total
222
(Table 2). A total of 597 serious injuries were noted, for an average of 2.7 serious injuries per fatality. The most common serious injuries involved the chest (162), head (143), and abdomen (117) (Table 3). Nonpreventable death was most commonly due to hemorrhage, head or spine injury, or cardiorespiratory injury (Table 4). Half of all nonpreventable deaths were due to hemorrhage. In the 10 patients who were felt to have suffered preventable or potentially preventable deaths, 7 were men and 3 were women. The average 1% was 25.8, with a range of 9 to 44. The average age was 47 years, with a range of 26 to 84 years. Seven injuries were related to blunt trauma; three were related to penetrating trauma. Death was most commonly due to exsanguination. Two patients died because of missed aortic injuries leading to exsanguinating hemorrhage, and three died because of ongoing hemorrhage with inadequate fluid resuscitation. Three patients died late in their care, 9 to 20 days after admission, from aspiration of gastric contents with subsequent respiratory arrest. While it is conceivable that none of these 3 aspiration deaths was preventable, our committee deemed them potentially preventable to ensure the absence of bias. One patient died 23 days after admission due to complications of previously unrecognized sepsis. This patient was monitored in the ICU and was noted to be developing progressive respiratory failure with associated hemodynamic instability. Despite early recognition by the nursing staff, the patient was not evaluated by a physician until he suffered a respiratory arrest requiring emergency intubation. He subsequently died because of an anoxic brain injury. Another patient died of a pulmonary embolus 5 days after admission with a grade IIIB femur fracture. No deep venous thrombosis (DVT) prophylaxis was administered (Table 5). It is Table
5. Preventable
Major
Injury
Transected pancreas Multi fx CHI GSW abd Femur fx GSW abd
Trauma
standard protocol to administer some form of DVT prophylaxis (minidose heparin, low-dose Warfarin, or sequential compression stockings in some combination) at each of the institutions. It is possible that this complication is not preventable, yet our committee considered it potentially preventable to ensure the absence of bias. Two of the patients who suffered preventable or potentially preventable deaths were cared for outside the Hillsborough County Trauma System. One patient suffered a gun shot wound (GSW) to the abdomen and was transported by private vehicle to a local hospital (not a trauma center) where she underwent celiotomy and later died of an aortic injury missed at exploration. While it is unusual for a gun shot wound of the aorta to be preventable, this patient presented with a stable blood pressure, and she had an unacceptable delay in time to surgery (1 hour 35 minutes). This same patient survived for several hours after her initial operation with the missed injury. In determining the preventable death rate, we eliminated the 272 scene fatalities. Scene fatalities are determined by protocol if rigor mortis is present, with decapitation, open head injury with arrest, or significant trauma history with total absence of vital signs and asystole. Of the 232 patients transported to hospitals, 4.3% (10/232) suffered preventable or possibly preventable deaths. If it is argued that the 143 patients who arrived at the emergency department undergoing CPR did not have a significant chance for survival, the preventable death rate would be 11.2% (10/89). It is highly likely that the current study overestimates the preventable death rate, particularly by including the 3 late deaths from gastric aspiration and the missed aortic injury cared for outside of the county trauma system. If these 4 deaths are excluded, the preventable death rate would be 7.0% (6/85). DISCUSSION
In 1966 the National Research Council’s Committee on Trauma and Committee on Shock labeled trauma “the neglected disease of modern society” (8). This designation was supported by several studies, the first by Von Wagoner (9) in 1961 showing a 33%
Deaths Age
Sex
ISS
27 35 26 35 26
M M F M M
25 44 34 9 25
Cause
of Death
Sepsis Gastric aspiration Aortic injury Pulmon. embolus Gastric aspiration
Comments Delay in Rx Arch bars Missed injury No DVT prophylaxis Aspirated during placement
of NG
138
E. Thoburn
preventable death rate. In 1986 the American College of Surgeons’ Committee on Trauma (8) developed criteria for the establishment of trauma systems and the designation of trauma centers. A study by West in 1988 (8) showed that only 2 states out of the 50 states, and the District of Columbia, had the essential components of a regionalized trauma system. The state of Florida passed its first trauma legislation in 1982, which required all hospitals seeking trauma center designation to be verified by the Department of Health and Rehabilitative Services (HRS) as meeting state guidelines. This legislation was then expanded in 1987, requiring HRS to develop a statewide trauma system (10). Prior to 1987 legislation, the preventable trauma death rate in Hillsborough County was found to be 22.6% of non-CNS deaths (4). Hillsborough County developed an organized trauma system in late 1988 that includes prehospital advanced life support capabilities, a transportation system with both ground and air transport, a communication network, designated trauma centers, and a county-wide trauma registry. Since the inception of the Hillsborough County trauma system there has been a significant decrease in preventable fatalities within the system, to 7.0% (6/85). This preventable death rate excludes all trauma patients who received CPR either in transport or at the scene. This exclusion is based on the assumption that there is no chance for survival in these patients. Traumatic cardiac arrest from blunt injury has almost uniform fatality, and cardiac arrest from penetrating injury has very high fatality rates. While others have stated (11) that 20% of patients who arrive at trauma centers classified as “dead on arrival” can be resuscitated and thereby survive, we believe that these data are both antiquated and hyperbole. We believe that a preventable death rate of 7% represents a reasonable application and interpretation of these data, as well as a significant improvement over the prior report from the same area. The small number of trauma centers (n = 3), prehospital advanced life support care systems (n = 2), and aeromedical advanced life support systems (n = 2), as well as the accurately detailed records and 100% autopsy availability, have allowed an in-depth review of our current system. In 1984, 78% of preventable deaths were due to system problems, most
et al.
notably, a delay in surgery. Cales (5) studied the effect of a regional trauma system in Orange County, California, and found a similar incidence (70%) of preventable deaths due to system problems prior to the development of a trauma system. Trauma systems have been proven to significantly reduce preventable deaths. Recently, evaluations of these deaths (12-24) have shown a change from system errors, as seen in cases of delayed or inadequate intervention, to errors in postoperative care. Currently, preventable deaths are generally (50%) late deaths or deaths due to errors in postoperative care. Davis and colleagues (12) studying the significance of treatment errors in trauma patients within a trauma system, found a similar (48%) preventable death rate caused by errors in postoperative care. To continue to improve care within County Trauma Systems, mechanisms should be established within the trauma systems to identify causes of preventable death through evaluation of prehospital, hospital, and medical examiners’ records. Trauma care providers, including paramedics, nurses, and physicians, should be educated in the causes of preventable deaths, including postoperative or postresuscitation care errors. Protocols should be developed to address the causes of preventable death. For example, defining parameters of the extent of exploration of body cavities (for example, opening the lesser sac to fully visualize the entire pancreas) and ensuring appropriate review of admission radiographic studies could further decrease missed injuries. Finally, establishing and enforcing nursing protocols that ensure communications with physicians and provide for appropriate care of common, but nonetheless potentially life-threatening situations, will diminish the occurrence of postoperative or postresuscitation care errors. With these enhancements, preventable death rates should continue to decrease, although they may never each zero. Most importantly, the total number of preventable deaths can be decreased through the reduction of overall trauma deaths. Prevention programs and public education should stress the dangers of drinking and driving, the importance of airbags, seatbelts, and helmet use, the relationships between violent crime and illegal drugs, and finally, the importance of utilizing an established trauma system in treating seriously injured persons.
REFERENCES 1. Hammond J, Gomez G, Eckes J. Trauma systems economic and political considerations. J Florida M. A. 1990;77:603-5. 2. Kreis DJ Jr, Plasencia G, Augenstein D, et al. Preventable
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System Care Improves Outcome
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