Heaney JB, Schroll R, Turney J, Stuke L, Marr AB, Greiffenstein P, Robledo R, Theriot A, Duchesne J, Hunt J. J. Trauma Acute Care Surg. 2019; ePub(ePub): ePub.
Affiliation
1 Tulane University School of Medicine, New Orleans Louisiana 2 Louisiana State University School of Medicine, New Orleans Louisiana 3 North Oaks Shock Trauma Program. Hammond Louisiana.
BACKGROUND: The Trauma Quality Improvement Project (TQIP) uses an injury prediction model for performance benchmarking. We hypothesize that at a level 1 high-volume penetrating trauma center, performance outcomes will be biased due to inclusion of patients with non-survivable injuries.
METHODS: Retrospective chart review was conducted for all patients included in the institutional TQIP analysis from 2013-2014 with length of stay (LOS) < 1 day to determine survivability of the injuries. O/E (observed-to-expected) mortality ratios were calculated before and after exclusion of these patients. Completeness of data reported to TQIP was examined.
RESULTS: 826 patients were reported to TQIP including 119 deaths. Non-survivable injuries accounted 90.9% of the deaths in patients with LOS ≤ 1 day. The O/E mortality ratio for all patients was 1.061, and the O/E ratio after excluding all patients with LOS <1 found to have non-survivable injuries was 0.895. Data for key variables were missing in 63.3% of patients who died in the ED, 50% of those taken to the OR and 0% of those admitted to the ICU. Charts for patients who died with LOS <1 day were significantly more likely than those who lived to be missing crucial.
CONCLUSION: This study shows TQIP inclusion of patients with non-survivable injuries biases outcomes at an urban trauma center. Missing data results in imputation of values, increasing inaccuracy. Further investigation is needed to determine if these findings exist at other institutions, and whether the current TQIP model needs revision to accurately identify and exclude patients with non-survivable injuries. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological.