Chelsea Brown

Preventable or potentially preventable mortality at a mature trauma center.

OBJECTIVE The objective of this study was to analyze the preventable and potentially preventable deaths occurring at a mature Level I trauma center. METHODS All trauma patients that died during their initial hospital admission during an 8-year period (January, 1998 to December, 2005) were analyzed. The deaths were initially reviewed at a weekly Morbidity and Mortality (M&M) conference followed by a multidisciplinary (Trauma Surgery, Critical Care, Emergency Medicine, Neurosurgery, Nursing, and Coroner) Combined Trauma Death Review Committee, and were classified into nonpreventable, potentially preventable, and preventable deaths. All preventable and potentially preventable deaths were identified for the purpose of the study. Quality improvement death forms included data on epidemiology, vital signs, injury severity, type of injury, probability of survival with Trauma and Injury Severity Score methodology, preventability (nonpreventable, potentially preventable, and preventable deaths), errors in the evaluation and management of the patient, and classification of errors (system, judgment, knowledge). Additional injury details, clinical course, circumstances leading to the death and autopsy findings were abstracted from the trauma registry and individual chart review. RESULTS During the study period, 35,311 patients meeting trauma registry criteria were admitted and a total of 2,081 (5.9%) deaths occurred. Fifty-one deaths were classified as preventable or potentially preventable deaths (0.1% of admissions, 2.5% of deaths). Eleven of them (0.53% of deaths) were classified as preventable and 40 (1.92% of deaths) as potentially preventable deaths. Mean age was 40 years, 66.7% were men, mean Injury Severity Score was 27, 74.5% were blunt. The most common cause of death was bleeding (20, 39.2%) followed by multiple organ dysfunction syndrome (14, 27.5%) and cardiorespiratory arrest (8, 15.6%). This was caused by a delay in treatment (27, 52.9%), clinical judgment error (11, 21.6%), missed diagnosis (6, 11.8%), technical error (4, 7.8%), and other (3, 5.9%). The deaths peaked at two time periods: 26 (51.1%) during the first 24 hours and 16 (31.4%) after 7 days. Only one patient (2.0%) died in the first hour. The most common location of death was the intensive care unit (28, 54.9%), operating room (13, 25.5%), and emergency room (5, 9.8%). CONCLUSION Preventable or potentially preventable deaths are rare but do occur at an academic Level I trauma center. Delay in treatment and error in judgment are the leading causes of preventable and potentially preventable deaths.

The effect of trauma center designation and trauma volume on outcome in specific severe injuries.

Objective:The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries. Background:Trauma centers are designated by the ACS into different levels on the basis of resources, trauma volume, and educational and research commitment. The criteria for trauma center designation are arbitrary and have never been validated. Methods:The National Trauma Data Bank study, which included patients >14 years of age and had injury severity score (ISS) >15, were alive on admission and had at least one of the following severe injuries: aortic, vena cava, iliac vessels, cardiac, grade IV/V liver injuries, quadriplegia, or complex pelvic fractures. Outcomes (mortality, intensive care unit stay, and severe disability at discharge) were compared among level I and II trauma centers and between centers within the same level designation but different volumes of severe trauma (<240 vs ≥240 trauma admissions with ISS >15 per year). The outcomes were adjusted for age (<65 ≥65), gender, mechanism of injury, hypotension on admission, and ISS (≤25 and >25). Results:A total of 12,254 patients met the inclusion criteria. Overall, level I centers had significantly lower mortality (25.3% vs 29.3%; adjusted odds ratio [OR], 0.81; 95% confidence interval [CI], 0.71–0.94; P = 0.004) and significantly lower severe disability at discharge (20.3% vs 33.8%, adjusted OR, 0.55; 95% CI, 0.44–0.69; P < 0.001) than level II centers. Subgroup analysis showed that cardiovascular injuries (N = 2004) and grades IV–V liver injuries (N = 1415) had a significantly better survival in level I than level II trauma centers (adjusted P = 0.017 and 0.023, respectively). Overall, there was a significantly better functional outcome in level I centers (adjusted P < 0.001). Subgroup analysis showed level I centers had significantly better functional outcomes in complex pelvic fractures (P < 0.001) and a trend toward better outcomes in the rest of the subgroups. The volume of trauma admissions with ISS >15 (<240 vs ≥240 cases per year) had no effect on outcome in either level I or II centers. Conclusions:Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes. The volume of major trauma admissions does not influence outcome in either level I or II centers. These findings may have significant implications in the planning of trauma systems and the billing of services according to level of accreditation.

A multisite randomized controlled trial of brief intervention to reduce drinking in the trauma care setting: How brief is brief?

Objective:Determine the efficacy of 3 brief intervention strategies that address heavy drinking among injured patients. Background:The content or structure of brief interventions most effective at reducing alcohol misuse after traumatic injury is not known. Methods:Injured patients from 3 trauma centers were screened for heavy drinking and randomly assigned to brief advice (n = 200), brief motivational intervention (BMI) (n = 203), or BMI plus a telephone booster using personalized feedback or BMI + B (n = 193). Among those randomly assigned, 57% met criteria for moderate to severe alcohol problems. The primary drinking outcomes were assessed at 3, 6, and 12 months. Results:Compared with brief advice and BMI, BMI + B showed significant reductions in the number of standard drinks consumed per week at 3 (&Dgr; adjusted means: −1.22, 95% confidence interval [CI]: −0.99, approximately −1.49, P = 0.01) and 6 months (&Dgr; adjusted means: −1.42, 95% CI: −1.14, approximately −1.76, P = 0.02), percent days of heavy drinking at 6 months (&Dgr; adjusted means: −5.90, 95% CI: −11.40, approximately −0.40, P = 0.04), maximum number of standard drinks consumed in 1 day at 3 (&Dgr; adjusted means: −1.38, 95% CI: −1.18, approximately −1.62, P = 0.003) and 12 months (&Dgr; adjusted means: −1.71, 95% CI: −1.47, approximately −1.99, P = 0.02), and number of standard drinks consumed per drinking day at 3 (&Dgr; adjusted means: −1.49, 95% CI: −1.35, approximately −1.65, P = 0.002) and 6 months (&Dgr; adjusted means: −1.28, 95% CI: −1.17, approximately −1.40, P = 0.01). Conclusions:Brief interventions based on motivational interviewing with a telephone booster using personalized feedback were most effective at achieving reductions in alcohol intake across the 3 trauma centers.