Analysis of preventable trauma deaths and inappropriate trauma care in a rural state

Survival of seriously injured patients first treated in rural hospitals

BACKGROUND

Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers.

METHODS

Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge.

RESULTS

Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital.

CONCLUSION

In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers

BACKGROUND

Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care.

METHODS

Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care.

RESULTS

Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25).

CONCLUSIONS

Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

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.

Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana

OBJECTIVE

To determine the rates of preventable mortality and inappropriate care, as well as the nature of treatment errors associated with pediatric traumatic deaths occurring in a rural state.

METHODS

Retrospective multidisciplinary consensus panel review of deaths attributed to mechanical trauma in children aged 18 years or less, occurring in Montana between October 1, 1989, and September 30, 1992. The care rendered in both preventable and nonpreventable cases was evaluated for appropriateness according to nationally accepted guidelines. Rates of pediatric preventable death and inappropriate care, as well as the nature of inappropriate care, were compared with that of the adult population.

RESULTS

One hundred thirty-eight cases were reviewed. One death (less than 1%) was judged frankly preventable, 11 deaths (8%) were judged possibly preventable, giving a total preventability rate of 9% for all cases reviewed. Considering only in-hospital deaths (n = 77), the total preventability rate was 16%. The rate of inappropriate care rendered for all deaths, regardless of preventability, was 36%. The rate of inappropriate care in the prehospital phase was 16%; for in-hospital deaths, it was 47%. In the emergency department (ED), the rate was 36%, and in post-ED care, 22%. In comparison to the adult population, the rates of preventable death (9% vs. 14%) and inappropriate care in the hospital phase (64% vs. 66%) were lower. Inappropriate care for the pediatric group was more prevalent in patients less than or equal to 14 years old. The nature of inappropriate care was most frequently associated with the management of respiratory problems, including airway control and management of chest trauma.

CONCLUSION

Preventable mortality from traumatic injuries in children in a rural state appears to be low, and lower than that reported for adult trauma victims in the same state. A preponderance of these preventable deaths occur in the subgroup of children less than or equal to 14 years if age. Inappropriate trauma care in children occurs frequently, particularly in the ED phase of care, and is primarily associated with the management of the airway and chest injuries. Education of ED primary care providers in basic principles of stabilization and initial treatment of the injured child 14 years old or younger may be the most effective method of reducing preventable trauma deaths in the rural setting.

Predicting regional variations in mortality from motor vehicle crashes

OBJECTIVE

To show that the previously-observed inverse relationship between population density and per-capita mortality from motor vehicle crashes can be derived from a simple mathematical model that can be used for prediction.

METHODS

The authors proposed models in which the number of fatal crashes in an area was directly proportional to the population and also to some power of the mean distance between hospitals. Alternatively, these can be parameterized as Weibull survival models. Using county and state data from the U.S. Census, the authors fitted linear regression equations on a logarithmic scale to test the validity of these models.

RESULTS

The southern states conformed to a different model from the other states. If an indicator variable was used to distinguish these groups, the resulting model accounted for 74% of the variation from state to state (Alaska excepted). After controlling for mean inter-hospital distance, the southern states had a per-capita mortality 1.37 times that of the other states.

CONCLUSIONS

Simply knowing the mean distance between hospitals in a region allows a fiarly accurate estimate of its per-capita mortality from vehicle crashes. After controlling for this factor, vehicle crash mortality per capita is higher in the southern states, for reasons yet to be explained.

Fatal trauma: the modal distribution of time to death is a function of patient demographics and regional resources

BACKGROUND

Unlike previous studies in an urban environment, this study examines traumatic death in a geographically diverse county in the southwestern United States.

METHODS

All deaths from blunt and penetrating trauma between November 15, 1991, and November 14, 1993, were included. As many as 150 variables were collected on each patient, including time of injury and time of death. Initial identification of cases was through manual review of death records. Information was supplemented by review of hospital records, case reports, and prehospital encounter forms.

RESULTS

A total of 710 traumatic deaths were analyzed. Approximately half of the victims, 52%, were pronounced dead at the scene. Of the 48% who were hospitalized, the most frequent mechanism of injury was a fall. Neurologic dysfunction was the most common cause of death. Two distinct peaks of time were found on analysis: 23% of patients died within the first 60 minutes, and 35% of patients died at 24 to 48 hours after injury.

CONCLUSIONS

Although there appears to continue to be a trimodal distribution of trauma deaths in urban environments, we found the distribution to be bimodal in an environment with a higher ratio of blunt to penetrating trauma.

A study of preventable trauma mortality in rural Michigan

OBJECTIVE

To determine the preventable death rate (PDR) and the frequency and types of inappropriate medical care in a large, rural region of Michigan.

DESIGN

A prospective study of all deaths caused by injury during a 1-year period.

METHODS

Preventability of death and appropriateness of care were determined using a structured implicit review process and expert panel. A second panel was convened to confirm the reliability of the review process.

MAIN RESULTS

One hundred fifty-five injury-related deaths underwent panel review. Four deaths (2.6%) were found to be definitely preventable and 16 (10.3%) possibly preventable, for a combined preventable death rate of 12.9%. Sixty-five deaths (41.9%) occurred in the emergency department or hospital; 18 of these (27.7%) were judged to be definitely preventable or possibly preventable. Forty-three episodes of inappropriate care were identified in 27 (17.4%) of the 155 cases reviewed. These occurred primarily in the emergency department and hospital rather than during prehospital care or transfer.

CONCLUSIONS

A relatively small percentage of trauma fatalities in rural Michigan could have been prevented by more appropriate or timely medical care. Efforts to improve the care of injured persons in rural Michigan should be directed primarily at the emergency department and inpatient phases of trauma system care.