Citation

Davenport R, Aylwin C, Ward E, Goosen J, McLeod J, Brohi K, Walsh M, Tai N. Inj. Extra 2008; 39(5): 157-157.

Affiliation

Royal London Hospital, UK; Johannesburg Hospital, South Africa

Copyright

(Copyright © 2008, Elsevier Publishing)

DOI

10.1016/j.injury.2007.11.293

PMID

unavailable

Abstract

Aim: A core function of established trauma systems is to improve performance through peer identification and review of potentially preventable mortality. The aim of this study was to evaluate the rate and cause of excess mortality occurring in an inner-city trauma centre that has invested substantial resources in developing a dedicated trauma service. Method: Retrospective peer review of all in-hospital deaths from April 2003-April 2004. Three external international trauma authorities graded each death as not preventable, possibly preventable, probably preventable or preventable according to the American College of Surgeons guidelines. Mortalities were then assigned a preventability score of 1-4 accordingly, with an aggregate score of =7 flagged as potentially preventable. Results: One hundred and seventy seven patients with an ISS greater than 15 were admitted, of whom 32 (18%) died. Twenty-nine patients who died from burn (n = 1), penetrating (n = 4) or blunt injury (n = 25) had retrievable post-mortem reports and were referred for peer review. The median (range) ISS and TRISS scores were 29 (17-75) and 36 (0-97). Median (range) preventability score was 4 (3-7). Mean weighted Kappa co-efficient for inter-observer variability was 0.345, indicating fair agreement between panel members. No death was considered entirely preventable. Five (17%) cases were assigned as potentially preventable. The principle variances from standard of care identified in these cases included delay to surgery/angio for haemorrhage control (4 cases), and delay in evacuating intracranial haematoma (1). Other variances identified in non-preventable deaths were failure to apply damage control principles during surgery and avoidable secondary brain injury (2). Conclusion: Delay to theatre or failure to utilise damage control principles was the primary cause of potentially avoidable death in major trauma patients. Robust, peer review systems assist objective analysis and the development of a culture of safety and quality, and are essential if excess trauma mortality is to be minimised.