A study of preventable trauma mortality in rural Michigan

Effect of trauma quality improvement initiatives on outcomes and costs at community hospitals: A scoping review

BACKGROUND

Due to complex geography and resource constraints, trauma patients are often initially transported to community or rural facilities rather than a larger Level I or II trauma center. The objective of this scoping review was to synthesize evidence on interventions that improved the quality of trauma care and/or reduced healthcare costs at non-Level I or II facilities.

METHODS

A scoping review was performed to identify studies implementing a Quality Improvement (QI) initiative at a non-major trauma center (i.e., non-Level I or II trauma center [or equivalent]). We searched 3 electronic databases (MEDLINE, Embase, CINAHL) and the grey literature (relevant networks, organizations/associations). Methodological quality was evaluated using NIH and JBI study quality assessment tools. Studies were included if they evaluated the effect of implementing a trauma care QI initiative on one or more of the following: 1) trauma outcomes (mortality, morbidity); 2) system outcomes (e.g., length of stay [LOS], transfer times, provider factors); 3) provider knowledge or perception; or 4) healthcare costs. Pediatric trauma, pre-hospital and tele-trauma specific studies were excluded.

RESULTS

Of 1046 data sources screened, 36 were included for full review (29 journal articles, 7 abstracts/posters without full text). Educational initiatives including the Rural Trauma Team Development Course and the Advanced Trauma Life Support course were the most common QI interventions investigated. Study outcomes included process metrics such as transfer time to tertiary care and hospital LOS, along with measures of provider perception and knowledge. Improvement in mortality was reported in a single study evaluating the impact of establishing a dedicated trauma service at a community hospital.

CONCLUSIONS

Our review captured a broad spectrum of trauma QI projects implemented at non-major trauma centers. Educational interventions did result in process outcome improvements and high rates of self-reported improvements in trauma care. Given the heterogeneous capabilities of community and rural hospitals, there is no panacea for trauma QI at these facilities. Future research should focus on patient outcomes like mortality and morbidity, and locally relevant initiatives.

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.

Assessment of prehospital care in canine trauma patients presented to Veterinary Trauma Centers: A VetCOT registry study

OBJECTIVE

To analyze the epidemiology of veterinary care in canine trauma patients prior to presentation to a Veterinary Trauma Center (VTC).

DESIGN

Retrospective observational cross-sectional study.

METHODS

 Retrospective descriptive analysis from 22,998 canine case records from the Veterinary Trauma Registry from September 2013 through April 2018. Analysis was focused on the type of injury, care provider, and care provided prior presentation to a VTC (pre-VTC care). A log-likelihood ratio test was used to test for association of outcome and pre-VTC care. Mann-Whitney U tests were used to compare modified Glasgow Coma Scale and Animal Trauma Triage (ATT) scores between pre-VTC and non-pre-VTC care groups.

MEASUREMENTS AND MAIN RESULTS

Pre-VTC care was provided in 5636 out of 22,998 dogs (24.5%) by veterinarians (81%), owners (19.6%), and first responders (0.03%). The most common nonveterinary interventions included wound care and bandaging in 42% and 39% of the patients, respectively. Mortality was higher in the pre-VTC care group (8.7% vs 7.5%); dogs receiving pre-VTC care were 1.5 times (95% confidence interval [CI], 1.15-1.88) more likely to die and 1.2 times (95% CI, 1.07-1.37) more likely to be euthanized. The ATT scores were significantly higher in dogs receiving pre-VTC care (mean = 2.53 vs 1.78; p < 0.0001).

CONCLUSION

Our data demonstrate that the majority of more severely injured dogs receiving pre-VTC care obtained care by a veterinarian. Dogs receiving pre-VTC care possessed a greater mortality rate but also a greater ATT score; therefore, mortality rate is more likely related to severity of trauma rather than reception of pre-VTC care. We propose that these data should prompt further research and education about prehospital care in veterinary medicine.

Preventable Trauma Deaths and Corrective Actions to Prevent Them: A 10-Year Comparative Study at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

OBJECTIVE

To determine the rate of preventable trauma deaths in an African hospital, identify the potential effect of improvements in trauma care over the past decade and identify deficiencies in care that still need to be addressed.

METHODS

A multidisciplinary panel assessed pre-hospital, hospital, and postmortem data on 89 consecutive in-hospital trauma deaths over 5 months in 2017 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For definitely and potentially preventable deaths, the panel identified deficiencies in care.

RESULTS

Thirteen percent (13%) of trauma deaths were definitely preventable, 47% potentially preventable, and 39% non-preventable. In comparison with a panel review in 2007, there was no change in total preventable deaths, but there had been a modest decrease in definitely preventable deaths (25% in 2007 to 13% in 2017, p = 0.07) There was a notable change in the pattern of deficiency (p = 0.001) with decreases in pre-hospital delay (19% of all trauma deaths in 2007 to 3% in 2017) and inadequate resuscitation (17 to 8%), but an increase in delay in treatment at the hospital (23 to 40%).

CONCLUSIONS

Over the past decade, there have been improvements in pre-hospital transport and in-hospital resuscitation. However, the preventable death rate remains unacceptably high and there are still deficiencies to address. This study also demonstrates that preventable death panel reviews are a feasible method of trauma quality improvement in the low- and middle-income country setting.

The preventability of trauma-related death at a tertiary hospital in Ghana: a multidisciplinary panel review approach

Introduction

The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency

Method

This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP).

Results

1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%–66.3%)

Conclusion

Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review.

•

Correcting delays in surgical care and inappropriate treatment of hemorrhage may improve trauma outcomes.

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Inadequacy of the clinical records within many low-resource settings hampers retrospective research system

•

The need for a robust, electronic trauma registry that collects detailed clinical information is apparent.

Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review

BACKGROUND

The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes.

METHODS

Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study.

RESULTS

After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%).

CONCLUSION

According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.

Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea

Objective

To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI).

Methods

We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Results

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

Conclusion

We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.

Prehospital trauma death review in the State of Victoria, Australia: a study protocol

INTRODUCTION

Regionalised trauma systems have been shown to improve outcomes for trauma patients. However, the evaluation of these trauma systems has been oriented towards in-hospital care. Therefore, the epidemiology and care delivered to the injured patients who died in the prehospital setting remain poorly studied. This study aims to provide an overview of a methodological approach to reviewing trauma deaths in order to assess the preventability, identify areas for improvements in the system of care provided to these patients and evaluate the potential for novel interventions to improve outcomes for seriously injured trauma patients.

METHODS AND ANALYSIS

The planned study is a retrospective review of prehospital and early in-hospital (<24 hours) deaths following traumatic out-of-hospital cardiac arrest that were attended by Ambulance Victoria between 2008 and 2014. Eligible patients will be identified from the Victorian Ambulance Cardiac Arrest Registry and linked with the National Coronial Information System. For patients who were transported to hospital, data will be linked the Victoria State Trauma Registry. The project will be undertaken in four phases: (1) survivability assessment; (2) preventability assessment; (3) identification of potential areas for improvement; and (4) identification of potentially useful novel technologies. Survivability assessment will be based on predetermined anatomical injuries considered unsurvivable. For patients with potentially survivable injuries, multidisciplinary expert panel reviews will be conducted to assess the preventability as well as the identification of potential areas for improvement and the utility of novel technologies.

ETHICS AND DISSEMINATION

The present study was approved by the Victorian Department of Justice and Regulation HREC (CF/16/272) and the Monash University HREC (CF16/532 - 2016000259). Results of the study will be published in peer-reviewed journals and reports provided to Ambulance Victoria, the Victorian State Trauma Committee and the Victorian State Government Department of Health and Human Services.

Injury Related Deaths in Singapore

Background

Injury is the commonest cause of morbidity and mortality amongst the younger age groups. Management of injuries has been identified as one of the major health issues facing our community. The study objective was to define the epidemiology of injury related deaths in Singapore.

Methods

A nationwide review of all deaths arising as a result of injury in 1995 was conducted.

Results

There were 913 cases with an injury mortality rate of 27 per 100,000 population. Ninety-seven percent (97%) were due to blunt injury. Falls from heights from deliberate self-harm was the commonest mechanism, followed by motor vehicle collisions (MVC). Fifty-two percent (52%) of MVC deaths were motorcyclists or pillion riders. Sixty-six percent (66%) of all deaths occurred in the prehospital phase. Central nervous system injury was the main cause of hospital deaths.

Conclusion

Results from this study will help our community focus on the appropriate preventive strategies to reduce mortality and the cost of injuries to our society.

The effect of scene time on survival

A review of the literature was carried out to determine the importance of pre-hospital scene times and how it can be affected. In the UK, and certain centres in North America, mortality and morbidity in critically injured patients appears to be related to scene times. The majority of these patients only require basic life support at the scene. Consequently the possible benefits of more advanced procedure need to be compared with the transportation period, the time needed to mobilize a medical team and skill proficiency. Cardiovascular resuscitation procedures in particular require reappraisal. Though haemostasis is essential, there is little evidence to support the use of fluid resuscitation in nontrapped urban patients with a significant haemorrhage problem. In contrast patients who are not bleeding do appear to benefit from advanced life support procedures even though this increases scene time. There is therefore a need for pre-hospital paramedic workers to triage patients so that appropriate resuscitation can be carried out.

A Call for Consensus on Methodology and Terminology to Improve Comparability in the Study of Preventable Prehospital Trauma Deaths: A Systematic Literature Review

OBJECTIVES

The study of preventable deaths is essential to trauma research for measuring service quality and highlighting avenues for improving care and as a performance indicator. However, variations in the terminology and methodology of studies on preventable prehospital trauma death limit the comparability and wider application of data. The objective of this study was to describe the heterogeneity in terminology and methodology.

METHODS

We performed a systematic literature review and report this using the PRISMA guidelines. Searches were conducted using PubMed (including Medline), Ovid, and Embase databases. Studies, with a full text available in English published between 1990 and 2015, meeting the following inclusion criteria were included: analysis of 1) deaths from trauma, 2) occurring in the prehospital phase of care, and 3) application of criteria to ascertain whether deaths were preventable. One author screened database results for relevance by title and abstract. The full text of identified papers was reviewed for inclusion. The reference list of included papers was screened for studies not identified by the database search. Data were extracted on predefined core elements relating to preventability reporting and definitions using a standardized form.

RESULTS

Twenty-seven studies meeting the inclusion criteria were identified: 12 studies used two categories to assess the preventability of death while 15 used three categories. Fifteen variations in the terminology of these categories and combination with death descriptors were found. Eleven different approaches were used in defining what constituted a preventable death. Twenty-one included survivability of injuries as a criterion. Methods used to determine survivability differed and eight variations in parameters for categorization of deaths were used. Nineteen used panel review in determining preventability with six implementing panel blinding. Panel composition varied greatly by expertise of personnel. Separation of prehospital deaths differed with 10 separating those dead at scene (DAS) and dead on arrival, three excluding those DAS, three excluding deaths prior to EMS arrival, and 11 not separating prehospital deaths.

CONCLUSIONS

The heterogeneity in methodology, terminology, and definitions of "preventable" between studies render data incomparable. To facilitate common understanding, comparability, and analysis, a commonly agreed ontology by the prehospital research community is required.

Minimizing preventable trauma deaths in a limited-resource setting: a test-case of a multidisciplinary panel review approach at the Komfo Anokye Teaching Hospital in Ghana

OBJECTIVE

Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care.

METHODS

A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006-2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified.

RESULTS

The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %).

CONCLUSIONS

A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.

Preventable mortality in geriatric hip fracture inpatients

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Cite this article: Bone Joint J 2014;96-B:1178–84.

Overall distribution of trauma-related deaths in Berlin 2010: advancement or stagnation of German trauma management?

BACKGROUND

Trauma is the leading cause of death among children, adolescents, and young adults. The latest data from the German Trauma Registry reveals a constant decrease in trauma mortality, indicating that 11.6 % of all trauma patients in 2010 died in hospital. Notably, trauma casualties dying before admission to hospital have not been systematically surveyed and analyzed in Germany.

METHODS

We conducted a prospective observational study of all traumatic deaths in Berlin, recording demographic data, trauma mechanisms, and causes/localization and time of death after trauma. Inclusion criteria were all deaths following trauma from 1 January 2010 to 31 December 2010.

RESULTS

A total of 440 trauma fatalities were included in this study, with a mortality rate of 13/100,000 inhabitants; 78.6 % were blunt injuries, and fall from a height >3 m (32.7 %) was the leading trauma mechanism. 32.5 % died immediately, 23.9 % died within 60 min, 7.7 % died within 1-4 h, 16.8 % died within 4-48 h, 11.1 % died <1 week later, and 8 % died >1 week after trauma. The predominant causes of death were polytrauma (45.7 %), sTBI (38 %), exsanguination (9.5 %), and thoracic trauma (3.2 %). Death occurred on-scene in 58.7 % of these cases, in the intensive care unit in 33.2 %, and in 2.7 % of the cases, in the emergency department, the operating room, and the ward, respectively.

CONCLUSIONS

Polytrauma is the leading cause of death, followed by severe traumatic brain injury (sTBI). The temporal analysis of traumatic death indicates a shift from the classic "trimodal" distribution to a new "bimodal" distribution. Besides advances in road safety, prevention programs and improvement in trauma management-especially the pre-hospital phase-have the potential to significantly improve the survival rate after trauma.

Increased population density of neurosurgeons associated with decreased risk of death from motor vehicle accidents in the United States

Object

Motor vehicle accidents (MVAs) are a leading cause of death and disability in young people. Given that a major cause of death from MVAs is traumatic brain injury, and neurosurgeons hold special expertise in this area relative to other members of a trauma team, the authors hypothesized that neurosurgeon population density would be related to reduced mortality from MVAs across US counties.

Methods

The Area Resource File (2009–2010), a national health resource information database, was retrospectively analyzed. The primary outcome variable was the 3-year (2004–2006) average in MVA deaths per million population for each county. The primary independent variable was the density of neurosurgeons per million population in the year 2006. Multiple regression analysis was performed, adjusting for population density of general practitioners, urbanicity of the county, and socioeconomic status of the county.

Results

The median number of annual MVA deaths per million population, in the 3141 counties analyzed, was 226 (interquartile range [IQR] 151–323). The median number of neurosurgeons per million population was 0 (IQR 0–0), while the median number of general practitioners per million population was 274 (IQR 175–410). Using an unadjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.90 fewer MVA deaths per million population (p < 0.001). On multivariate adjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.01 fewer MVA deaths per million population (p < 0.001), with a respective decrease in MVA deaths of 0.03 per million population for an increase in 1 general practitioner (p = 0.007). Rural location, persistent poverty, and low educational level were all associated with significant increases in the rate of MVA deaths.

Conclusions

A higher population density of neurosurgeons is associated with a significant reduction in deaths from MVAs, a major cause of death nationally. This suggests that the availability of local neurosurgeons is an important factor in the overall likelihood of survival from an MVA, and therefore indicates the importance of promoting neurosurgical education and practice throughout the country.

Does direct transport to provincial burn centres improve outcomes? A spatial epidemiology of severe burn injury in British Columbia, 2001-2006

BACKGROUND

In Canada and the United States, research has shown that injured patients initially treated at smaller emergency departments before transfer to larger regional facilities are more likely to require longer stays in hospital or suffer greater mortality. It remains unknown whether transport status is an independent predictor of adverse health events among persons requiring care from provincial burn centres.

METHODS

We obtained case records from the British Columbia Trauma Registry for adult patients (age ≥ 18 yr) referred or transported directly to the Vancouver General Hospital and Royal Jubilee Hospital burn centres between Jan. 1, 2001, and Mar. 31, 2006. Prehospital and in-transit deaths and deaths in other facilities were identified using the provincial Coroner Service database. Place of injury was identified through data linkage with census records. We performed bivariate analysis for continuous and discrete variables. Relative risk (RR) of prehospital and in-hospital mortality and hospital stay by transport status were analyzed using a Poisson regression model.

RESULTS

After controlling for patient and injury characteristics, indirect referral did not influence RR of in-facility death (RR 1.32, 95% confidence interval [CI] 0.54- 3.22) or hospital stay (RR 0.96, 95% CI 0.65-1.42). Rural populations experienced an increased risk of total mortality (RR 1.22, 95% CI 1.00-1.48).

CONCLUSION

Transfer status is not a significant indicator of RR of death or hospital stay among patients who received care at primary care facilities before transport to regional burn centres. However, significant differences in prehospital mortality show that improvements in rural mortality can still be made.

Effects of Early Prehospital Life Support to War Injured: The Battle of Jalalabad, Afghanistan

Objective:

To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989–1992.

Method:

The outcomes of simple trauma care administered from 1989–1990 were compared to the outcomes of advanced trauma care administered from 1991–1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan.

Results:

A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% confidence interval for difference = 9.7–15.4%).

Conclusion:

In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources.

Comparison of mortality associated with sepsis in the burn, trauma, and general intensive care unit patient: a systematic review of the literature

The purpose of this systematic review of the literature was to determine the association of sepsis with mortality in the severely injured adult patient by means of a comparative analysis of sepsis in burn and trauma injury with other critically ill populations. The MEDLINE (PubMed), Cochrane Library, and ProQuest databases were searched. The following keywords and MeSH headings were used: "sepsis," septicemia," "septic shock," "epidemiology," "burns," "thermal injury," "trauma," "wounds and injuries," "critical care," "intensive care," "outcomes," and "mortality." Included studies were clinical studies of adult burn, trauma, and critically ill patients that reported survival data for sepsis. Thirty-eight articles were reviewed (9 burn, 11 trauma, 18 general critical care). The age of burn (<45 years) and trauma (34-49 years) groups was lower than the general critical care (57-64 years) population. Sepsis prevalence varied with trauma-injured patients experiencing fewer episodes (2.4%-16.9%) contrasted with burn patients (8%-42.5%) and critical care patients (19%-38%). Survival differed with trauma patients experiencing a lower rate of mortality associated with sepsis (7%-36.9%) compared with the burn (28%-65%) and critical care (21%-53%) groups. This study is the first to compare sepsis outcomes in three distinct patient populations: burn, trauma, and general critical care. Trauma patients tend to have relatively low sepsis-associated mortality; burn patients and the older critical care population have higher prevalence of sepsis with worse outcomes. Great variability of criteria to identify septic patients among studies compromises population comparisons.

Preventability of trauma deaths in a Dutch Level-1 trauma centre

BACKGROUND

Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability.

METHODS

All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus.

RESULTS

Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies.

CONCLUSIONS

The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care.

Evidence for quality indicators to evaluate adult trauma care: a systematic review

OBJECTIVE

Multiple quality indicators are available to evaluate adult trauma care, but their characteristics and outcomes have not been systematically compared. We sought to systematically review the evidence about the reliability, validity, and implementation of quality indicators for evaluating trauma care.

DATA SOURCES

Search of MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 14, 2009; the Gray Literature; select journals by hand; reference lists; and articles recommended by experts in the field.

STUDY SELECTION

Studies were selected that evaluated the reliability, validity, or the impact of one or more quality indicators on the quality of care delivered to patients ≥ 18 yrs of age with a major traumatic injury.

DATA EXTRACTION

Reviewers with methodologic and content expertise conducted data extraction independently.

DATA SYNTHESIS

The literature search identified 6869 citations. Review of abstracts led to the retrieval of 538 full-text articles for assessment; 40 articles were selected for review. Of these, 20 (50%) articles were cohort studies and 13 (33%) articles were case series. Five articles used control groups, including three before and after case series, a case-control study, and a nonrandomized controlled trial. A total of 115 quality indicators in adult trauma care was identified, predominantly measures of hospital processes (62%) and outcomes (17%) of care. We did not identify any posthospital or secondary injury prevention quality indicators. Reliability was described for two quality indicators, content validity for 22 quality indicators, construct validity for eight quality indicators, and criterion validity for 46 quality indicators. A total of 58 quality indicators was implemented and evaluated in three studies. Eight quality indicators had supporting evidence for more than one measurement domain. A single quality indicator, peer review for preventable death, had both reliability and validity evidence.

CONCLUSIONS

Although many quality indicators are available to measure the quality of trauma care, reliability evidence, validity evidence, and description of outcomes after implementation are limited.

A population-based analysis of injury-related deaths and access to trauma care in rural-remote Northwest British Columbia

BACKGROUND

Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes.

METHODS

Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner's Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006.

RESULTS

The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination.

CONCLUSION

Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

Mannequin or standardized patient: participants' assessment of two training modalities in trauma team simulation

Background

Trauma team training using simulation has become an educational compensation for a low number of severe trauma patients in 49 of Norway's 50 trauma hospitals for the last 12 years. The hospitals' own simple mannequins have been employed, to enable training without being dependent on expensive and advanced simulators. We wanted to assess the participants' assessment of using a standardized patient instead of a mannequin.

Methods

Trauma teams in five hospitals were randomly exposed to a mannequin or a standardized patient in two consecutive simulations for each team. In each hospital two teams were trained, with opposite order of simulation modality. Anonymous, written questionnaires were answered by the participants immediately after each simulation. The teams were interviewed as a focus group after the last simulation, reflecting on the difference between the two simulation modalities. Outcome measures were the participants' assessment of their own perceived educational outcome and comparison of the models, in addition to analysis of the interviews.

Results

Participants' assessed their educational outcome to be high, and unrelated to the order of appearance of patient model. There were no differences in assessment of realism and feeling of embarrassment. Focus groups revealed that the participants felt that the choice between educational modalities should be determined by the simulated case, with high interaction between team and patient being enhanced by a standardized patient.

Conclusion

Participants' assessment of the outcome of team training seems independent of the simulation modality when the educational goal is training communication, co-operation and leadership within the team.

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION

Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed.

MATERIALS AND METHODS

A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies.

RESULTS

Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death.

DISCUSSION

Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Surgical trauma referrals from rural level III hospitals: should our community colleagues be doing more, or less?

BACKGROUND

Rural citizens die more frequently because of trauma than their urban counterparts. Skill maintenance is a potential issue among rural surgeons because of infrequent exposure to severely injured patients. The primary goal was to evaluate the outcomes of multiple injuries patients who required a laparotomy after referral from level III trauma centers.

METHODS

All severely injured patients (injury severity score >12) referred to a level I trauma center from level III hospitals, during a 48-month period were evaluated. Comparisons between referrals (level III and IV) as well as survivors and nonsurvivors used standard statistical methodology.

RESULTS

One thousand two hundred and thirty patients (35%) were transferred from level III (33%) and level IV (67%) centers (43% underwent an operative procedure). Only 13% required a laparotomy, whereas 87% needed procedures from other subspecialists. Referred patients had a mean injury severity score of 28, length of stay of 28 days, and mortality rate of 26%. More patients arrived hemodynamically unstable from level IV (55%) versus level III (35%) hospitals (p < 0.05). Nonsurvivors from level III centers were more likely to transfer via aircraft (100%) than from level IV hospitals (55%) (p < 0.05). Most (91%) definitive general surgery procedures could have been completed by surgeons at level III centers; however, 90% also had multisystem injuries requiring treatment by other subspecialists.

CONCLUSIONS

Most severely injured patient referrals from level III and IV trauma centers in Western Canada are appropriate. The lack of consistent subspecialty coverage mandates most transfers from level III hospitals. This data will be used to engage rural Alberta physicians in an educational outreach program.

Overtriage in trauma - what are the causes?

BACKGROUND

Different criteria are employed to activate trauma teams. Because of a growing concern about overtriage, the objective of this study was to investigate the performance of our trauma team's activation protocol.

METHODS

Injured patients with trauma team activation (TTA), admission to an intensive care unit or surgical intermediate care unit with a trauma diagnosis, or trauma-related death in the emergency department were investigated retrospectively from 1 January 2004 to 31 December 2005. Different TTA criteria were analysed with respect to sensitivity, positive predictive value (PPV) and overtriage (1 - PPV).

RESULTS

Eight hundred and nine patients were included, 185 (23%) of whom had an Injury Severity Score (ISS) of more than 15. The performance of our protocol showed a sensitivity of 87%, PPV of 22% and overtriage of 78%. The mechanism of injury as a TTA criterion had a sensitivity of 14%, PPV of 7% and overtriage of 93%. Physiological/anatomical criteria and interfacility transfer showed higher PPV and less overtriage. Undertriage (no TTA despite ISS > 15) was identified in 23 patients (13%), 18 of whom were hospital transfers.

CONCLUSION

A TTA protocol based on physiological, anatomical and interfacility transfer criteria seems to yield a higher precision than, in particular, that based on mechanism of injury criteria. Because of substantial overtriage in our hospital, the TTA protocol needs to be re-evaluated.

Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004

BACKGROUND

Effective combat trauma management strategies depend upon an understanding of the epidemiology of death on the battlefield.

METHODS

A panel of military medical experts reviewed photographs and autopsy and treatment records for all Special Operations Forces (SOF) who died between October 2001 and November 2004 (n = 82). Fatal wounds were classified as nonsurvivable or potentially survivable. Training and equipment available at the time of injury were taken into consideration. A structured analysis was conducted to identify equipment, training, or research requirements for improved future outcomes.

RESULTS

Five (6%) of 82 casualties had died in an aircraft crash, and their bodies were lost at sea; autopsies had been performed on all other 77 soldiers. Nineteen deaths, including the deaths at sea were noncombat; all others were combat related. Deaths were caused by explosions (43%), gunshot wounds (28%), aircraft accidents (23%), and blunt trauma (6%). Seventy of 82 deaths (85%) were classified as nonsurvivable; 12 deaths (15%) were classified as potentially survivable. Of those with potentially survivable injuries, 16 causes of death were identified: 8 (50%) truncal hemorrhage, 3 (19%) compressible hemorrhage, 2 (13%) hemorrhage amenable to tourniquet, and 1 (6%) each from tension pneumothorax, airway obstruction, and sepsis. The population with nonsurvivable injuries was more severely injured than the population with potentially survivable injuries. Structured analysis identified improved methods of truncal hemorrhage control as a principal research requirement.

CONCLUSIONS

The majority of deaths on the modern battlefield are nonsurvivable. Improved methods of intravenous or intracavitary, noncompressible hemostasis combined with rapid evacuation to surgery may increase survival.

Clinician-performed focused sonography for the resuscitation of trauma

Traumatic death remains pandemic. The majority of preventable deaths occur early and are due to injuries or physiologic derangements in the airway, thoracoabdominal cavities, or brain. Ultrasound is a noninvasive and portable imaging modality that spans a spectrum between the physical examination and diagnostic imaging. It allows trained examiners to immediately confirm important syndromes and answer clinical questions. Newer technologies greatly increase the fidelity, accessibility, ease of use, and informatic manipulation of the results. The early bedside use of focused ultrasound as the initial imaging modality used to detect hemoperitoneum and hemopericardium in the resuscitation of the injured patient has become an accepted standard of care. Widespread dissemination of basic ultrasound skills and technology to facilitate this brings ultrasound to many resuscitative and critical care areas. Although not as widely appreciated, the focused use of ultrasound may also have a role in detecting hemothoraces and pneumothoraces, guiding airway management, and detecting increased intracranial pressure. Intensivists generally utilize a treating philosophy that requires the real-time integration of many divergent sources of information regarding their patients' anatomy and physiology. They are therefore positioned to take advantage of focused resuscitative ultrasound, which offers immediate diagnostic information in the early care of the critically injured.

Trauma care at rural level III trauma centers in a state trauma system

BACKGROUND

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care.

METHODS

During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail.

RESULTS

A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5.

CONCLUSIONS

Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

Rural Motor Vehicle Crash Risk of Death is Higher After Controlling for Injury Severity

BACKGROUND

Motor vehicle crash (MVC) mortality rates are inversely related to population density. The purpose of this study was to analyze if there is a regional variation in the risk of MVC death after controlling for injury severity.

METHODS

The study utilized the Crash Outcome Data Evaluation System (CODES) data set in Nebraska. All fatal or injury-related crashes during a 4-year period (1996 through 1999) were analyzed. Injury Severity Scores (ISSs) were calculated from the CODES listed International Classification of Diseases diagnoses. Logistic regression analysis was performed to analyze the odds ratio for death in three rural county groupings compared with urban locations.

RESULTS

During the 4-year period, 56,727 people were injured and 1,237 were killed in 38,493 MVCs. Of these, 45,222 (78%) records had complete information on variables of interest. In addition, 28,859 (50%) records had enough information to calculate an ISS. A total of 22,181 (39%) records had complete information on the variables of interest and ISSs. After adjusting for the effects of speed limit, age, and alcohol involvement (but not ISS), the odds of death were 1.24 (1.01-1.53) higher in the large, non-adjacent and 1.38 (1.14-1.66) small, non-adjacent rural counties. After adjusting for the effect of ISS, the odds of death were 1.98 (1.18-3.31) higher in the small, non-adjacent rural counties.

CONCLUSION

After controlling for ISS, the risk of MVC death is nearly twice as high in the most rural counties in Nebraska. This finding suggests that variation in medical care may contribute to this regional variation.

Critical care issues in the early management of severe trauma

Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. Preventability of trauma deaths has been reported as high as 76% and as low as 1% in mature trauma systems. Critical care errors may occur in a half of hospital trauma deaths, in most of the cases contributing to the death. The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.

Preventable deaths in patients admitted from emergency department

BACKGROUND

There is limited data about how appropriate medical care is in the emergency department (ED).

OBJECTIVES

To investigate the rate and types of preventable deaths among patients with early mortality after emergency admission from the ED.

METHODS

We retrospectively reviewed charts of early mortality (defined as mortality which occurred within 24 hours after admission from the ED) over a 3 year period. Those patients with terminal cancer or out of hospital cardiac arrest (OHCA) at presentation were excluded. Two independent assessors reviewed each eligible chart and determined whether early mortality was preventable. Any disagreements were resolved through discussion between the investigators. A mortality event was considered preventable if actions or missed actions were identified that would have prevented the death. The types of preventability were categorised as misdiagnosis, delayed diagnosis, and inappropriate medical management. Interrater reliability in the initial determination was assessed using Cohen kappa statistic.

RESULTS

Over a 3 year period, 210 early mortality cases were identified. Excluding patients with terminal cancer or OHCA, the rate of preventable deaths was 25.8% (32/124). The types of preventability were inappropriate medical management (17 patients), delayed diagnosis (eight), and misdiagnosis (seven). There was good agreement between assessors with a Cohen kappa statistic of 0.81.

CONCLUSIONS

Preventable deaths in emergency admitted patients with early mortality are not uncommon. Analysis and identification of preventability early mortality by using a chart based method may be used as a quality assurance index in emergency medical care.

Rural and urban traffic fatalities, vehicle miles, and population density

The purpose of this study was to evaluate the effect of population density on the rates of motor vehicle mortality in rural and urban areas, while controlling for vehicle miles traveled (VMT). Rural and urban data for traffic mortality, VMT, and population were obtained for each state from the Federal Highway Administration for 1998-2000. Linear regression was used to estimate the effect of population density, VMT per capita, southern location, and presence of a trauma system on mortality. Variation in rural mortality rate (per 100,000 population) was proportional to rural VMT per capita, but population density and southern location were also independent predictors, together accounting for 91% of this variation. Variation in urban mortality rates was not affected by population density, but urban rates were also higher in the south. The exposure-based rural mortality rate (deaths per 100 million VMT) was inversely proportional to population density, which along with southern location explained 41% of the variation from state to state. The presence of a state trauma system did not measurably affect mortality. After controlling for VMT and southern location, state population density was a moderately strong predictor of rural but not urban traffic mortality rates.

Preventable Trauma Death in Tehran: An Estimate of Trauma Care Quality in Teaching Hospitals

OBJECTIVE

The purpose of this study was estimate the number of preventable trauma deaths in teaching hospitals in Tehran.

METHODS

We evaluated the complete prehospital, hospital, and postmortem data of 70 trauma patients who had died during a 1-year period in two of the largest university hospitals in Tehran with a multidisciplinary panel of experts.

RESULTS

Panel members identified 26% of all trauma deaths as preventable deaths. From 31 non-central nervous system-related deaths, 17 and 6 cases were identified as surely preventable and probably preventable, respectively. In central nervous system-related deaths, 5% of the deaths overall (2 of 38 cases) were identified as surely preventable or probably preventable. Sixty-four cases of medical errors were identified in 31 trauma deaths and 80% of these errors were directly related to the death of the patients.

CONCLUSION

The high preventable trauma death rate in our teaching hospitals indicates that a relatively significant percentage of trauma fatalities could have been prevented by improving prehospital and in-hospital trauma care.

Death after injury in rural Norway: high rate of mortality and prehospital death

BACKGROUND

Finnmark is a rural and remote area in Norway with a sparse population and long distances. Trauma-related mortality has been consistently above the Norwegian national average for the last 20 years. Although the causes of death are well established, very little is known about the time and place of death. This information has implications for the organization of emergency services in rural areas. We examined all trauma deaths over a five-year period in order to inform the debate on how best to reduce our above-average mortality rate.

METHODS

A retrospective study of all deaths after trauma (ICD-9 E800-E999) during the years 1991-95 using data obtained from the National Registry of Death.

RESULTS

Of the 183 cases found, 130 deaths were due to trauma using definitions comparable to similar studies. The mortality rate was 77 per 100,000 inhabitants per year. Death occurred in the prehospital phase in 85% of cases. Seventy-two per cent of all deaths (regardless of location) occurred within the first h after injury, eight per cent from 1 to 4 h and the remaining 20% occurred after 4 h.

CONCLUSION

When planning interventions to reduce the mortality rate from trauma in rural areas, a high proportion of prehospital deaths should be expected. The high number of patients who are found dead (which can only be reduced by injury prevention) must be taken into account. Measures to reduce 'preventable' causes of death by bystanders should be evaluated. Further knowledge of exact mechanisms of death in the prehospital phase is required.

Motor vehicle crash-related mortality is associated with prehospital and hospital-based resource availability

BACKGROUND

To date, attempts to assess the relationship between motor vehicle collision (MVC)-related mortality and medical resources availability have largely been unsuccessful.

METHODS

Information regarding sociodemographic characteristics, prehospital resources, and hospital-based resources for each county (n = 67) in the state of Alabama was obtained. MVC-related mortality rates (deaths per 1,000 collisions) by county were calculated and compared according to prehospital and hospital-based resource availability within each county after correcting for sociodemographic factors.

RESULTS

Counties with 24-hour availability of a general surgeon, orthopedic surgeon, neurosurgeon, computed tomographic scanner, and operating room were shown to have decreased MVC-related mortality (relative risk [RR], 0.88). The same was true for those counties with hospitals classified as Level I-II (RR, 0.71) and Level III-IV (RR, 0.83) trauma centers compared with counties with no trauma centers.

CONCLUSION

Appropriate, readily available hospital-based resources are associated with lower MVC-related mortality rates. This information may be useful in trauma system planning and development.

Elderly injury: a profile of trauma experience in the Sunshine (Retirement) State

OBJECTIVE

By using mandatory discharge data from a state agency, the records of 116,687 patients hospitalized for treatment of injury were evaluated to develop an epidemiologic and demographic profile of this population and to compare outcomes of patients treated in state-designated trauma centers (TC) with those treated in nontrauma centers (NTC).

METHODS

Injury severity was calculated by using the International Classification Injury Severity Score methodology to compute individual diagnosis survival risk ratios from 698,187 reported diagnoses, and then by using these survival risk ratios to determine probability of survival for every patient. The population was then categorized by age, injury type, treatment facility designation, injury severity as indicated by probability of survival, and discharge disposition. Incidence of potentially preventable death was compared between TC and NTC, as was the effect on outcome of noninjury comorbidity.

RESULTS

The average age of this population was 58 +/- 26 years with significant skew toward the elderly in NTC (mean age, 62 +/- 26 years). The most commonly encountered injuries likewise reflected the elderly nature of this population. Although 71.3% received care in NTC, the majority of severely injured were treated in TC. Potentially preventable mortality (>0.5) was significantly lower in TC. The effect of noninjury comorbidity on outcome was better managed by TC, both in terms of decreased mortality and in proportion of patients discharged home.

CONCLUSION

These data demonstrate the unique characteristics of injury victims treated in the state of Florida and indicate that the developing trauma system is demonstrating productivity in terms of avoidance of preventable death, efficient management of noninjury comorbid problems, and more complete recovery as indicated by proportion of patients discharged to home.

Effects of alcohol on the geographic variation of driver fatalities in motor vehicle crashes

OBJECTIVE

To determine whether the increased risk of dying in a rural vs nonrural motor vehicle crash (MVC) can be attributed to driver demographics, crash characteristics, or police-reported alcohol use.

METHODS

A retrospective cohort study was conducted, comparing all rural (116,242) and a 20% random sample of nonrural (104,197) Michigan drivers involved in an MVC during 1994-1996. Data consisted of all police-reported traffic crashes on public roadways. A logistic regression model was created, using survival as the dependent variable and gender, age, crash characteristics, and rural or nonrural county as independent variables. Driver alcohol use, as reported by the investigating officer, was introduced into the model, and the effect was analyzed.

RESULTS

Nonsurvivors represented 0.2% of the total; 99.8% were survivors. Police-reported alcohol use was reported for 3.9% of drivers. Drivers in rural MVCs were more likely to be male, to be more than 50 years of age, to have been drinking alcohol, and to have more severe vehicle deformation as a result of the MVC. The relative risk (RR) for MVC nonsurvivors was 1.69 [95% confidence interval (CI) = 1.3 to 2.1] times higher for drivers in rural than nonrural counties. After adjusting for demographic and crash characteristics, the RR was 1.56 (95% CI = 1.2 to 1.9). Controlling for alcohol and its interactions decreased the RR to 1.26 (95% CI = 0.6 to 2.4), a nonsignificant difference between rural and nonrural MVC mortalities.

CONCLUSIONS

Alcohol use by drivers in Michigan was a significant contributor for nonsurvivors of rural crashes. Efforts to decrease rural MVC mortality must address alcohol use.