A study of preventable trauma mortality in rural Michigan

Review of evidence regarding trauma system effectiveness resulting from panel studies

OBJECTIVE

The objectives this study are to elucidate the advantages and disadvantages of the panel method for evaluating the quality of trauma care and to review the individual and collective evidence in support of regionalized trauma care derived from these studies.

METHOD

A review of the published literature was conducted and identified 10 panel studies that compared appropriateness of care and/or the preventability of deaths occurring either across hospitals in a trauma system versus non-trauma system, in a defined region before and after implementation of a trauma system, between trauma center and non-trauma center hospitals within a defined region, or across hospitals of varying levels of care presystem.

RESULTS

Panel studies vary widely in the approaches used to elicit judgments; low rates of inter-rater reliability have been reported. The strength of the evidence derived from panel studies in support of trauma system effectiveness must be reviewed in this context.

CONCLUSION

All panel studies are classified as providing weak, Class III evidence. Yet, collectively they provide some face validity in support of the hypothesis that treatment at a trauma versus non-trauma center may be associated with less inappropriate care and fewer preventable deaths among the seriously injured.

Gut intramucosal pH as an early indicator of effectiveness of therapy for hemorrhagic shock

OBJECTIVE

To determine the value of intramucosal pH for evaluating the effectiveness of treatment for hemorrhagic shock.

DESIGN

Randomized, controlled trial.

SETTING

University center, animal laboratory.

SUBJECTS

Eighteen piglets, weighing 17 to 23 kg.

INTERVENTIONS

Anesthetized animals were bled to a mean arterial pressure (MAP) of 40 to 50 mm Hg and a 70% reduction in cardiac output during a 1-hr period. This state was maintained for the next hour. The piglets were treated with crystalloid solution to restore cardiac output and MAP during the subsequent 80 mins of the experiment. Some animals were given vasoactive drugs during volume therapy to modulate splanchnic perfusion and increase the diversity of values of various variables.

MEASUREMENTS AND MAIN RESULTS

Systemic hemodynamic and oxygen transport variables were monitored. Tissue oxygen tensions were measured in the liver and abdominal subcutaneous tissue layer. Gut intramucosal pH (pHi) was determined, using a balloon tonometer. The animals were divided into responders (n=9) and nonresponders (n=9) according to whether pHi increased or decreased during resuscitation. Hemodynamic and oxygen transport variables improved in the group of responders. In the group of nonresponders, values decreased. Liver and subcutaneous oxygen tensions increased during the initial phase of resuscitation in both groups but decreased after 30 mins in the nonresponder group.

CONCLUSIONS

The change in pHi during the first hour of resuscitation could be used to divide animals treated uniformly from a hemodynamic point of view into two distinct groups with seemingly different outcome. The minimally invasive method could be of value for early evaluation of the results of treatment of hemorrhagic shock.

Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria

BACKGROUND

Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified problems in the management of traffic fatalities. Its two evaluative committees have additionally assessed the potential preventability of death. Previous studies have shown only poor to fair reproducibility of death judgments.

METHODS

Problems in the management of 60 consecutive road traffic fatalities and the potential preventability of death were independently evaluated by the two committees. Inter-rater and inter-committee concordance were analyzed using the kappa statistic.

RESULTS

Reproducibility was high. Inter-committee agreement on nonpreventable, potentially preventable, and preventable death judgments was high (kappa = 0.73, 95% confidence interval = 0.57-0.89). Agreement within the two evaluative committees was also high (average weighted kappa = 0.73 and 0.74). There was good agreement between committees on problems identified, including those contributing to death.

CONCLUSION

The high kappa concordance on preventable death judgments and the agreement on problem identification supports the reproducibility of the methodology used.

Fatal and non-fatal farm injuries to children and adolescents in the United States, 1990-3

OBJECTIVE

Examine the current magnitude of the injury problem to children and adolescents on farms, and to compare these data to that from 1978-83.

DATA SOURCES

US National Center for Health Statistics Mortality Multiple Cause of Death Tapes for the years 1991-3, and the US Consumer Product Safety Commission National Electronic Injury Surveillance System for data on emergency department visits for 1990-3.

SUBJECTS

Children and adolescents 19 years and younger injured on farms.

RESULTS

There were an average of 104 deaths per year due to injuries occurring on farms. The rate of 8.0 deaths per 100,000 child farm residents is 39% lower than in 1979-81. More of the deaths occurred in hospital than previously. There were an average of 22,288 emergency department treated injuries per year. The rate of 1717 injuries per 100,000 child farm residents is 10.7% higher than 1979-83. Males were injured more frequently than females. Tractors accounted for 20.9% of all injuries, followed by horses (8.4%), all terrain vehicles and minibikes (8.0%), and farm wagons (7.7%).

CONCLUSIONS

Farm injuries continue to be a major problem to children living on farms. While improved medical care may have contributed to the reduction in mortality, the continued high rate of injuries warrants study of a variety of intervention strategies to reduce the injury toll. There is also a need for ongoing injury surveillance to provide accurate data on the farm injury problem.