Lisa K. McIntyre

Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

Objective:To identify patterns of errors contributing to inpatient trauma deaths. Methods:All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data. Results:In 9 years, there were 44,401 trauma patient admissions and 2594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths. Conclusions:Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

Long-term outcomes of ground-level falls in the elderly.

BACKGROUND For older adults, even ground-level falls (GLFs) can result in multiple injuries and are associated with significant morbidity and mortality. Previous studies have focused on in-hospital outcomes and patients with isolated injuries. Our study examined outcomes following discharge for older adults who were hospitalized following a GLF. METHODS A retrospective cohort study of patients older than 65 years admitted to a regional Level I trauma center, from 2005 to 2008, after a GLF was conducted. Hospital trauma registry data were linked to state hospital discharge data and the death certificate registry. Skilled nursing facilities (SNFs) were contacted to verify ultimate patient placement, with follow-up through December 2010. Kaplan-Meier and Cox proportional hazards models were used to analyze postdischarge mortality. RESULTS There were 1,352 consecutive admissions; 48% had an Injury Severity Score (ISS) greater than 15, and 12% died during admission. Of the patients who survived hospitalization, 51% were discharged to an SNF, 33% to home without assistance, 6% to home with assistance, and 5% to inpatient rehabilitation facilities. Within 1 year of injury, 44.6% of the patients were readmitted. The 1-year mortality for the overall cohort was 33%; for patients who were discharged alive, the 1-year mortality was 24%. After adjusting for confounders, patients discharged to an SNF had a threefold greater risk of 1-year mortality (hazard ratio, 2.82; 95% confidence interval, 1.86–4.28), compared with patients discharged home with no assistance. Of the patients discharged to an SNF, 48% died by the end of the follow-up period (mean, 28.2 months), and 61% of these patients died while residing at an SNF. CONCLUSION GLFs in the elderly result in severe injury, high rate of readmissions, and increased mortality, both in-hospital and after discharge. Overall, only one third of the patients were discharged home to independent living. Future efforts should examine whether improvements in the quality of posthospital care affect both mortality and functional outcomes. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Acquiring basic surgical skills: is a faculty mentor really needed?

BACKGROUND We evaluated the impact of expert instruction during laboratory-based basic surgical skills training on subsequent performance of more complex surgical tasks. METHODS Forty-five junior residents were randomized to learn basic surgical skills in either a self-directed or faculty-directed fashion. Residents returned to the laboratory 2 days later and were evaluated while performing 2 tasks: skin closure and bowel anastomosis. Outcome measures included Objective Structured Assessment of Technical Skill, time to completion, final product quality, and resident perceptions. RESULTS Objective Structured Assessment of Technical Skill, time to completion, and skin esthetic ratings were not better in the faculty-directed group, although isolated improvement in anastomotic leak pressure was seen. Residents perceived faculty-directed training to be superior. CONCLUSIONS Our data provided minimal objective evidence that faculty-directed training improved transfer of learned skills to more complex tasks. Residents perceived that there was a benefit of faculty mentoring. Curriculum factors related to training of basic skills and subsequent transfer to more complex tasks may explain these contrasting results.

β-Blocker Continuation After Noncardiac Surgery: A Report From the Surgical Care and Outcomes Assessment Program

BACKGROUND Despite limited evidence of effect, β-blocker continuation has become a national quality improvement metric. OBJECTIVE To determine the effect of β-blocker continuation on outcomes in patients undergoing elective noncardiac surgery. DESIGN, SETTING, AND PATIENTS The Surgical Care and Outcomes Assessment Program is a Washington quality improvement benchmarking initiative based on clinical data from more than 55 hospitals. Linking Surgical Care and Outcomes Assessment Program data to Washingtons hospital admission and vital status registries, we studied patients undergoing elective colorectal and bariatric surgical procedures at 38 hospitals between January 1, 2008, and December 31, 2009. MAIN OUTCOME MEASURES Mortality, cardiac events, and the combined adverse event of cardiac events and/or mortality. RESULTS Of 8431 patients, 23.5% were taking β-blockers prior to surgery (mean [SD] age, 61.9 [13.7] years; 63.0% were women). Treatment with β-blockers was continued on the day of surgery and during the postoperative period in 66.0% of patients. Continuation of β-blockers both on the day of surgery and postoperatively improved from 57.2% in the first quarter of 2008 to 71.3% in the fourth quarter of 2009 (P value <.001). After adjusting for risk characteristics, failure to continue β-blocker treatment was associated with a nearly 2-fold risk of 90-day combined adverse event (odds ratio, 1.97; 95% CI, 1.19-3.26). The odds were even greater among patients with higher cardiac risk (odds ratio, 5.91; 95% CI, 1.40- 25.00). The odds of combined adverse events continued to be elevated 1 year postoperatively (odds ratio, 1.66; 95% CI, 1.08-2.55). CONCLUSIONS β-Blocker continuation on the day of and after surgery was associated with fewer cardiac events and lower 90-day mortality. A focus on β-blocker continuation is a worthwhile quality improvement target and should improve patient outcomes.

Gossypiboma: Tales of Lost Sponges and Lessons Learned

OBJECTIVE To review the details surrounding cases of patients found to have retained laparotomy sponges after surgical procedures and share policy changes that have led to process improvements at one academic medical center. DESIGN Retrospective medical record review as part of a quality improvement process. SETTING Single academic medical center. PATIENTS Patients identified through the quality improvement process as having had retained foreign bodies after surgery. CONCLUSIONS Sentinel events such as retained foreign bodies after surgery require intensive review to identify systems problems. This can lead to protocol changes to improve the process. After a series of incidents, protocol changes at our institution have led to no further incidents of retained foreign bodies.

The incidence of post-discharge surgical site infection in the injured patient.

BACKGROUND Approximately 50% of surgical site infections (SSI) after elective surgery occur after discharge. Adequate surveillance for these infections requires a mechanism for post-discharge follow up. The incidence of SSI after injury is as high as 30%. As post-discharge follow up in the trauma population is difficult, we set out to ascertain the incidence of post-discharge SSI in a cohort of high-risk trauma patients. METHODS Patients (n = 268) enrolled in a randomized controlled trial of leukoreduced versus regular blood transfusions were evaluated either in person or by structured telephone survey 28 days after admission regarding the presence of SSI. Inclusion criteria were age >17 years and blood transfusion within 24 hours of injury. RESULTS Among the 268 patients, 39 (15%) developed a SSI. There were 27 SSI identified in hospital and 13 identified in the post-discharge period after a median length of stay of 17 days (one patient had more than one SSI). Although the 13 patients who developed a SSI in the post-discharge period comprised only 7% (13 of 194) of the cohort that had at least one operative procedure and survived to discharge, these patients represented 33% (13 of 39) of all patients who developed a SSI. CONCLUSION Despite their prolonged length of stay compared with elective surgical patients, a significant proportion of SSI after injury occurs after discharge. These data support the need for a post-discharge surveillance system in either clinical trials or for quality assurance.

Improving Resident Engagement in Quality Improvement and Patient Safety Initiatives at the Bedside The Advocate for Clinical Education (ACE)

Quality improvement (QI) and patient safety (PS) are essential competencies in residency training; however, the most effective means to engage physicians remains unclear. The authors surveyed all medicine and surgery physicians at their institution to describe QI/PS practices and concurrently implemented the Advocate for Clinical Education (ACE) program to determine if a physician-centered program in the context of educational structures and at the point of care improved performance. The ACE rounded with medicine and surgery teams and provided individual and team-level education and feedback targeting 4 domains: professionalism, infection control, interpreter use, and pain assessment. In a pilot, the ACE observed 2862 physician-patient interactions and 178 physicians. Self-reported compliance often was greater than the behaviors observed. Following ACE implementation, observed professionalism behaviors trended toward improvement; infection control also improved. Physicians were highly satisfied with the program. The ACE initiative is one coaching/feedback model for engaging residents in QI/PS that may warrant further study.

Gunshot-Induced Aorto-Left Atrial Fistula Diagnosed by Intraoperative Transesophageal Echocardiography

Aorto-left atrial fistula (AAF) is rarely encountered in clinical practice, and the early diagnosis can be very challenging. This report describes a unique case of AAF caused by a gunshot injury and the pivotal role of transesophageal echocardiography for diagnosis and assessment.