Identifying preventable trauma death: does autopsy serve a role in the peer review process?

Preventable death in trauma: A systematic review on definition and classification

PURPOSE

Trauma-related preventable death (TRPD) has been used to assess the management and quality of trauma care worldwide. However, due to differences in terminology and application, the definition of TRPD lacks validity. The aim of this systematic review is to present an overview of current literature and establish a designated definition of TRPD to improve the assessment of quality of trauma care.

METHODS

A search was conducted in PubMed, Embase, the Cochrane Library and the Web of Science Core Collection. Including studies regarding TRPD, published between January 1, 1990, and April 6, 2021. Studies were assessed on the use of a definition of TRPD, injury severity scoring tool and panel review.

RESULTS

In total, 3,614 articles were identified, 68 were selected for analysis. The definition of TRPD was divided in four categories: I. Clinical definition based on panel review or expert opinion (TRPD, trauma-related potentially preventable death, trauma-related non-preventable death), II. An algorithm (injury severity score (ISS), trauma and injury severity score (TRISS), probability of survival (Ps)), III. Clinical definition completed with an algorithm, IV. Other. Almost 85% of the articles used a clinical definition in some extend; solely clinical up to an additional algorithm. A total of 27 studies used injury severity scoring tools of which the ISS and TRISS were the most frequently reported algorithms. Over 77% of the panels included trauma surgeons, 90% included other specialist; 61% emergency medicine physicians, 46% forensic pathologists and 43% nurses.

CONCLUSION

The definition of TRPD is not unambiguous in literature and should be based on a clinical definition completed with a trauma prediction algorithm such as the TRISS. TRPD panels should include a trauma surgeon, anesthesiologist, emergency physician, neurologist, and forensic pathologist.

Synergistic Effects of Forensic Medicine and Traumatology: Comparison of Clinical Diagnosis Autopsy Findings in Trauma-Related Deaths

BACKGROUND

Trauma is the third leading cause of death worldwide after cardiovascular and oncologic diseases. Predominant causes of trauma-related death (TD) are severe traumatic brain injury (sTBI), hemorrhagic shock, and multiple organ failure. An analysis of TD is required in order to review the quality of trauma care and grasp how well the entire trauma network functions, especially for the most severely injured patients. Furthermore, autopsies not only reveal hidden injuries, but also verify clinical assumed causes of death.

MATERIAL

During the study period of 3 years, a total of 517 trauma patients were admitted to our supraregional University Centre of Orthopaedics and Traumatology in Dresden. 13.7% (71/517) of the patients died after trauma, and in 25 cases (35.2%), a forensic autopsy was instructed by the federal prosecutor. The medical records, death certificates, and autopsy reports were retrospectively evaluated and the clinical findings matched to autopsy results.

RESULTS

The observed mortality rates (13.7%) were 4.2% less than expected by the calculated RISC II probability of survival (mortality rate of 17.9%). The most frequent trauma victims were due to falls >3 m (n = 29), followed by traffic accidents (n = 28). The median ISS was 34, IQR 25, and the median New ISS (NISS) was 50, IQR 32. Locations of death were in emergency department (23.9%), ICU (73.2%), OR and ward (1.4%, respectively). Clinicians classified 47.9% of deaths due to sTBI (n = 34), followed by 9.9% thoracic trauma and multiple organ failure (n = 7), 8.4% multiple trauma (n = 6), and 2.8% hypoxia and exsanguination (n = 2). In 18.3%, cases were unspecific or other causes of death recorded on the death certificates. Evident differences with evident clinical consequences were ascertained in 4% (n = 1) and marginal clinical consequences in 24% (6/25). In 16% (4/25), marginal differences with minor forensic consequences were revealed.

CONCLUSIONS

Even in a supraregional trauma center, specialized in multiple trauma management (4.2% survival benefit), room for improvement exists in more than a quarter of all casualties. This underlines the need for higher autopsy rates to uncover missed injuries and to understand the pathomechanism in each trauma fatality. This would also help to uncover potential insufficiencies in clinical routines with regard to diagnostics. The interdisciplinary cooperation of trauma surgeons and forensic pathologists can increase the quality of trauma patient care.

The Value Proposition for Pathologists: A Population Health Approach

The transition to a value-based payment system offers pathologists the opportunity to play an increased role in population health by improving outcomes and safety as well as reducing costs. Although laboratory testing itself accounts for a small portion of health-care spending, laboratory data have significant downstream effects in patient management as well as diagnosis. Pathologists currently are heavily engaged in precision medicine, use of laboratory and pathology test results (including autopsy data) to reduce diagnostic errors, and play leading roles in diagnostic management teams. Additionally, pathologists can use aggregate laboratory data to monitor the health of populations and improve health-care outcomes for both individual patients and populations. For the profession to thrive, pathologists will need to focus on extending their roles outside the laboratory beyond the traditional role in the analytic phase of testing. This should include leadership in ensuring correct ordering and interpretation of laboratory testing and leadership in population health programs. Pathologists in training will need to learn key concepts in informatics and data analytics, health-care economics, public health, implementation science, and health systems science. While these changes may reduce reimbursement for the traditional activities of pathologists, new opportunities arise for value creation and new compensation models. This report reviews these opportunities for pathologist leadership in utilization management, precision medicine, reducing diagnostic errors, and improving health-care outcomes.

Spectral analysis of heart rate variability for trauma outcome prediction: an analysis of 210 ICU multiple trauma patients

PURPOSE

This study aimed to test and compare short-term spectral HRV indices with most used trauma scorings in outcome prediction of multiple trauma, and then to explore the efficacy of their combined application.

METHODS

A prospective study was conducted for patients with blunt multiple trauma admitted to an emergency intensive care unit (ICU) between January 2016 and December 2017. Short-term spectral HRV indices on admission were measured, including normalized low-frequency power (nLF), normalized high-frequency power (nHF), and the nLF/nHF ratio. Injury severity score (ISS), new injury severity score (NISS), and revised trauma score (RTS) were evaluated for each patient, as well as probability of survival (Ps) by trauma and injury severity score (TRISS) model. The primary outcome was 30-day mortality and secondary outcomes were incidence of multiple organ dysfunction syndrome (MODS) and length of ICU stay.

RESULTS

Two hundred and ten patients were recruited. The nLF/nHF ratio, RTS, and Ps_(TRISS) were independent predictors of 30-day mortality, while nLF/nHF, NISS and RTS were independent predictors of MODS. The area under the receiver operating characteristic (ROC) curve (AUC) of nLF/nHF for 30-day mortality prediction was 0.924, comparable to RTS (0.951) and Ps_(TRISS) (0.892). AUC of nLF/nHF-RTS combination was 0.979, significantly greater than that of each alone. Combination of nLF/nHF and Ps_(TRISS) showed an increased AUC (0.984) compared to each of them. The nLF/nHF ratio presented a similar AUC (0.826) to NISS (0.818) or RTS (0.850) for MODS prediction. AUC of nLF/nHF-RTS combination was 0.884, significantly greater than that of nLF/nHF. Combination of nLF/nHF and NISS showed a greater AUC (0.868) than each alone. The nLF/nHF ratio, NISS, RTS, and Ps_(TRISS) were correlated with length of ICU stay for survivors, with correlation coefficients 0.476, 0.617, - 0.588, and - 0.539.

CONCLUSIONS

These findings suggest that the short-term spectral analysis of HRV might be a potential early tool to assess injury severity and predict outcome of multiple trauma. Combination of nLF/nHF and conventional trauma scores can provide more accuracy in outcome prediction of multiple trauma.

Do Autopsies Still Matter? The Influence of Autopsy Data on Final Injury Severity Score Calculations

BACKGROUND

Despite a proven record of identifying injuries missed during clinical evaluation, the effect of autopsy on injury severity score (ISS) calculation is unknown. We hypothesized that autopsy data would alter final ISS and improve the accuracy of outcome data analyses.

MATERIALS AND METHODS

All trauma deaths from January 2010 through June 2014 were reviewed. Trauma registrars calculated Abbreviated Injury Scale and ISS from clinical documentation alone. The most detailed available autopsy report then was reviewed, and AIS/ISS recalculated. Predictors of ISS change were identified using multivariate logistic regression.

RESULTS

Seven hundred thirty-nine deaths occurred, of which 682 (92.3%) underwent autopsy (31% view-only, 3% with preliminary report, and 66% with full report). Patients undergoing full autopsy had a lower median age (39 versus 74 years, P < 0.01), a higher rate of penetrating injury (41.7% versus 0%, P < 0.01), and a higher emergency department mortality rate (30.8% versus 0%, P < 0.01) than those receiving view-only autopsy. Incorporating autopsy findings increased mean ISS (21.3 to 29.6, P < 0.001) and the percentage of patients with ISS ≥ 25 (49.9% to 69.2%, P < 0.001). Multivariate analysis identified length of stay, death in the emergency department, full rather than view-only autopsy, and presenting heart rate as variables associated with ISS increase.

CONCLUSIONS

Autopsy data significantly increased ISS values for trauma deaths. This effect was greatest in patients who died early in their course. Targeting this group, rather than all trauma patients, for full autopsy may improve risk-adjustment accuracy while minimizing costs.