Preventable trauma death rate in Daegu, South Korea

Relationships between trauma death, disability, and geographic factors: a systematic review

OBJECTIVE

Trauma is a global health problem. The causes of trauma-related deaths are diverse and may depend in part on socioeconomic and geographical factors; however, there have been few studies addressing such relationships. The aim of this study was to investigate the relationships between trauma and geographical factors in order to support policy recommendations to reduce trauma-related deaths and disability.

METHODS

In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched international and Korean databases to retrieve relevant literature published between 2000 and 2020.

RESULTS

Thirty-two studies showed a positive relationship between the outcomes of major trauma and geographical factors. The study investigated regional factors including economic factors such as size of urban areas, gross domestic product, and poverty rate, as well as hospital parameters, such as presence of trauma centers and number of hospital beds. There was a tendency toward higher mortality rates in rural and low-income areas, and most of the studies reported that the presence of trauma centers reduced trauma-related mortality rates.

CONCLUSION

Our study showed that geographic factors influence trauma outcomes. The findings suggest geographical considerations be included in care plans to reduce death and disability caused by trauma.

A Propensity Score-Matched Comparison of In-Hospital Mortality between Dedicated Regional Trauma Centers and Emergency Medical Centers in the Republic of Korea

Background

In the Republic of Korea, a trauma care system was not created until 2012, at which point regional trauma centers (RTCs) were established nationwide. In accordance with the national emergency care system and legislation, regional and local emergency medical centers (EMCs) also treat patients presenting with trauma. The aim of the present study was to assess whether treatment in RTCs is truly associated with better patient outcomes than that in EMCs by means of propensity score-matched comparisons and to identify populations that would benefit from treatment in RTCs.

Methods

This study analyzed the data of patients with consecutive emergency visits between January 1, 2018, and December 31, 2018, collected in the National Emergency Department Information System registry. Data from RTCs, designated regional EMCs, or local EMCs were included; data from smaller emergency departments were excluded because, in Korea, dedicated RTCs are established only in hospitals with regional or local EMCs. Propensity scores for treatment in RTCs or EMCs were estimated by logistic regression using linear terms. Mortality rates in RTCs and EMCs were compared between the matched samples.

Results

The in-hospital mortality rates in the matched cases treated in RTCs and EMCs were 1.4% and 1.6%, respectively. The odds ratio for in-hospital mortality in RTCs over EMCs was 0.984 (95% confidence interval: 0.813–1.191). Among the subgroups evaluated, the subgroup of patients with injuries involving the chest or lower limbs showed a significant difference in the in-hospital mortality rate.

Conclusion

There was no significant difference in the overall severity-adjusted mortality rate between patients treated in RTCs and EMCs. Treatment in an RTC might benefit those with injuries involving the chest or lower limbs.

Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines

BACKGROUND

The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable.

AIM

This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors.

METHODS

We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122).

RESULTS

Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities.

CONCLUSION

Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

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.

Analysis of polymorphonuclear cell apoptosis and inflammatory cytokines in trauma patients in the emergency department

INTRODUCTION

Durring the immune-inflammation cascade in trauma patients, the roles of polymorphonuclear cells (PMNs) and inflammatory cytokines are very important; however, there is little research in this area, especially for patients with multiple traumas. This study aimed to determine the effects of inflammatory cytokines and apoptosis of PMNs on the prognosis of patients with multiple traumas in tertiary medical centers.

MATERIALS AND METHODS

The study subjects were patients with multiple severe traumas who had visited the emergency department. More specifically, patients with multiple traumas included those who had visited the emergency department because of trauma and presented with trauma in more than two body regions. The severity of the traumas was evaluated using the Glasgow coma scale (GCS) and abbreviated injury scale (AIS). In addition, prognostic factors including the length of the hospital stay in the intensive care unit (ICU), the condition upon discharge from the emergency department (discharge, hospitalization in a general ward, hospitalization in the intensive care unit, transfer to a different hospital, surgical operation, death, etc.), outcome of the surgical operation, and presence of infection were examined. To examine the inflammatory response factors, blood samples were obtained. Flow cytometry was performed to analyze PMN cell apoptosis. For comparative analysis, the patients were categorized according to their admission type and the presence of hemorrhagic shock.

RESULTS

Ninety-six patients were enrolled in the study (mean age 51.4 ± 16.7 years). When inpatients that had been admitted to the ICU were compared with general-ward inpatients, apoptosis, ROS, MIF, TNF-α, and IL-6 levels were found to be higher, with levels of TNF-α showing a statistically significant difference (726.7 ± 1524.2 vs. 37.5 ± 83.0, P = 0.037). PMN cell apoptosis was rarely observed in shock patients compared with non-shock patients (5.1 ± 5.8 vs. 15.0 ± 26.1, P = 0.004). When subjects were classified based on AIS (11 points or more, no more than 11 points), no significant differences were found between groups.

CONCLUSION

Findings of laboratory tests targeting trauma patients who required hospitalization showed that levels of inflammatory cytokines such as TNF-α were increased in ICU-hospitalized patients. PMN cell apoptosis was reduced according to the initial laboratory data of patients with hemorrhagic shock in the emergency department.

Distribution of Trauma Deaths in a Province of Korea: Is "Trimodal" Distribution Relevant Today?

PURPOSE

This study was designed to provide a basis for building a master plan for a regional trauma system by analyzing the distribution of trauma deaths in the most populous province in Korea.

MATERIALS AND METHODS

We investigated the time distribution to death for trauma patients who died between January and December 2017. The time distribution to death was categorized into four groups (within a day, within a week, within a month, and over a month). Additionally, the distribution of deaths within 24 hours was further analyzed. We also reviewed the distribution of deaths according to the cause of death and mechanism of injury.

RESULTS

Of the 1546 trauma deaths, 328 cases were included in the final study population. Patients who died within a day were the most prevalent (40.9%). Of those who died within a day, the cases within an hour accounted for 40.3% of the highest proportion. The majority of trauma deaths within 4 hours were caused by traffic-related accidents (60.4%). The deaths caused by bleeding and central nervous system injuries accounted for most (70.1%) of the early deaths, whereas multi-organ dysfunction syndrome/sepsis had the highest ratio (69.7%) in the late deaths. Statistically significant differences were found in time distribution according to the mechanism of injury and cause of death (p<0.001).

CONCLUSION

The distribution of overall timing of death was shown to follow a bimodal pattern rather than a trimodal model in Korea. Based on our findings, a suitable and modified trauma system must be developed.

External injuries, trauma and avoidable deaths in Agincourt, South Africa: a retrospective observational and qualitative study

OBJECTIVE

Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies.

SETTING

Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa.

PARTICIPANTS

Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals.

METHODS

A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care.

RESULTS

Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems.

CONCLUSIONS

A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

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.