Preventable Deaths Among Trauma Patients

POLSKI PRZEGLĄD CHIRURGICZNY 2008, 80, 3, 139–145

10.2478/v10035-008-0016-3

PREVENTABLE DEATHS AMONG TRAUMA PATIENTS

DOMINIKA KOŁODZIEJCZYK-WOJTCZAK1, MACIEJ BARZDO2, ELŻBIETA BALCERZYK-BARZDO3, WOJCIECH GASZYŃSKI1, JAROSŁAW BERENT2, DARIUSZ PIOTROWSKI3 Department of Anesthesiology and Intensive Care, Medical University in Łódź1 Kierownik: prof. dr hab. W. Gaszyński Department of Forensic Medicine, Medical University in Łódź2 Kierownik: dr hab. J. Berent, prof. nadzw. Department of Emergency and Trauma Medicine, Medical University in Łódź3 Kierownik: dr n. med. D. Piotrowski

The aim of the study was to assess the effectiveness of the medical rescue service in the city of Łódź and its surrounding areas. Material and methods. The records of the forensic-medical postmortems conducted at the Institute of Forensic Medicine Medical University in Łódź in 2004 were analyzed. For further analysis, the cases of adults who died of mechanical injury resulting from an accident were chosen. Taking into consideration the autopsy diagnosis, the degree of the individual injuries was defined with the use of the Abbreviated Injury Scale (AIS). Next, the Injury Severity Score (ISS) and the New Injury Severity Score (NISS) were calculated. In cases where specialist medical assistance was given, the medical documentation was analyzed, and the clinical condition of the injured was assessed using the Revised Trauma Scale (RTS), followed by estimation of the probability of survival with the use of the TRISS (Trauma Revised Injury Severity Score). Results and conclusions. Among the analyzed 194 cases of death caused by a mechanical injury resulting from an accident, 19 cases (9.8%) were recognized as preventable (ISS 0-14 or/and NISS 0-14 and/or TRISS >75%). It was established that the deaths assessed as preventable were caused by early or late injury complications, which even correct treatment cannot always prevent. Key words: trauma, injury, preventable death, probability of survival, injury scales, injury severity score

The processes aimed at introducing an integrated medical emergency system began in Poland in 1999. The expected effect of introducing such a system is an increase in the effectiveness of the emergency services due to the creation of conditions enabling specialist medical assistance that is available sooner and that is of better quality. A decrease in the percentage of preventable deaths as a function of total deaths should be the result of such changes. Thus, research aimed at assessing the presently existing and still developing medical emergency system is recommended, so that in the future it is possible to assess the advantages of the introduced changes.

In order to assess the effectiveness of the rescue actions carried out by the medical emergency system services, hospital emergency wards and specialist hospital wards, an analysis of the number of preventable deaths out of the total number of deaths can be used. Nevertheless, it seems useful to focus attention on deaths caused by mechanical injury, as the appropriate scales measuring injury severity can be used in order to assess these types of cases, and the probability of survival can thereby be estimated. Results obtained in this way are objective, and a comparative analysis can be done using results obtained in this way and the results of other research done elseUnauthenticated Download Date | 12/9/16 5:04 PM

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where at other times. Rejecting cases of homicide and suicide from the researched group allows for elimination of cases where preventable death was caused by the intentional delay of medical assistance, rather than by the insufficient actions of the medical emergency services. Among the injury scales, there are three main anatomical, physiological and anatomical-physiological scoring systems. The anatomical scoring systems are based on the classification of the injury of individual organs; the most widely used is the Abbreviated Injury Scale (AIS), created in 1971 and updated many times (1, 5, 13, 14, 15). According to the 1985 update, the AIS allocates six body regions and six degrees of injury severity, which are ranked on a scale of 1 to 6. The AIS score is used to assess the Injury Severity Score (ISS), introduced by Baker in 1974 (1). The ISS is calculated by adding the square of the AIS points allocated to the three most severe injuries in three different body regions (ISS = AIS12 + AIS22 + AIS32). ISS may maximally reach a score of 75 points, while if any injury is estimated as unsurvivable (AIS of 6) then the ISS is automatically assigned the maximum score. Similar to ISS is the New Injury Severity Score (NISS), in which the three highest AIS scores are used even if they are assigned to the same body region (3, 4, 7, 8, 16). The physiological scoring systems take into account the clinical condition exponents, such as arterial blood pressure, pulse, breathing frequency and level of consciousness. One such scoring system is the Revised Trauma Score (RTS) (18) created in 1989, measuring the level of consciousness by the GCS (Glasgow Coma Scale) created in 1975 (17), as well as the systolic arterial blood pressure and breathing frequency. In 1983 the TRISS (Trauma Revised Injury Severity Score) methodology was designed, connecting the ISS and the RTS and, after taking the patient’s age into consideration, enabling a calculation of the probability of survival (6, 10, 11, 12) and, further on, isolating preventable deaths. The probability of survival (Ps) can be calculated using the formula1 : Ps = 1/1+e-b 1

The TRISS calculator available at was used in the research (39)

where e = 2.718282 and b = b0 + (b1 x RTS) + (b2 x RTS) + (b3 x A)2 RTS is a score calculated according to the Revised Trauma Score, and A is age index (below 54 years of age = 0, above 54 years of age = 1). It is assumed that the non-preventable deaths, which cannot be avoided regardless of the medical action taken, are those in which the probability of survival is less than 25% (22, 23, 30). The probability of survival in the potentially preventable deaths, which can be prevented by an immediate implementation of optimal diagnostic and medical procedures, is 2575%. In the case of preventable deaths, which for theoretic-statistic reasons should not occur, the probability of survival is above 75%. In cases in which the clinical condition of the injured is unknown, the probability of survival can be evaluated on the basis of the ISS or NISS. Similarly to other studies, it was assumed that ISS or NISS scores of 0-14 correspond to minor injuries, 15-35 moderate to severe injuries and 36-75 critical and unsurvivable injuries (28, 29, 33). This study aims to assess the effectiveness of the medical rescue services actions, as well as specialist treatment, in the hospital wards in the city of Łódź and its vicinity3 in 2004. MATERIAL AND METHODS The records of the forensic-medical postmortems conducted at the Institute of Forensic Medicine Medical University in Łódź in 2004 were analyzed. In further analysis, the cases of adults (aged 18 and older) who died of mechanical injury resulting from an accident (the cases of homicide and suicide deaths, where medical assistance might have been intentionally delayed, were dismissed) were chosen. Taking into account the results of the autopsy, the severity of each injury was assessed using the Abbreviated Injury Scale (AIS). Next, the Injury Severity Score (ISS) and the New Inju-

2

3

The sum of weighted coefficients derived from the Walker-Duncan regression divided into blunt and acute injuries, ranging from -2.6676 to 1.1430. The Łódź province – population 2.6 million people (city inhabitants 64.7%), area of 18.2 thousand square kilometres; city of Łódź – population of 779 thousand people, area of 295 thousand square kilometres. (37) Unauthenticated Download Date | 12/9/16 5:04 PM

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ry Severity Score (NISS) were calculated. The research did not take into account the clinical diagnosis, as such a diagnosis may differ considerably from the autopsy diagnosis; this is especially true considering that actual injuries, which are sometimes severe and constitute the cause of death, are often not recognized under clinical conditions (2, 36). Moreover, it was not possible to obtain full medical documentation in all cases, which prevented a thorough analysis of the discrepancies between the clinical and autopsy examinations. The medical documentation of the cases in which specialist medical assistance was given was analyzed, and the clinical condition of the injured was assessed with the use of Revised Trauma Score (RTS); however, it was not possible to gain access to the documentation in all such cases. Next, in cases where the clinical condition data were missing, the probability of survival was assessed on the basis of the ISS and NISS values. In cases where the medical assistance was given and the authors gained access to the medical documentation, the probability of survival was calculated with the use of the TRISS (Trauma Revised Injury Severity Score) methodology. RESULTS At the Institute of Forensic Medicine in Łódź in 2004, 301 forensic-medical autopsies of people deceased due to mechanical injury were conducted. Among these were the corpses of 226 men (75%) aged 18-94 (average age 48) and 75 women (25%) aged 18-92 (average age 56). In 239 (79%) cases, the injury occurred within the city limits, and in the remaining 62 (21%) cases it occurred outside the city limits. In 184 (61.1%) cases, death occur-

red at the scene, before the arrival of emergency services; in 5 (1.7%) cases, death occurred at the scene, after the arrival of emergency services; in 9 (3%) cases, death occurred in the ambulance on the way to the hospital; in 103 (34.2%) cases, death occurred during hospitalization. After dismissing the cases of homicide and suicide, 194 cases remained for further analysis. In the analyzed group, there were 141 (73%) men aged 18-94 (average age 49) and 53 (27%) women aged 18-92 (average age 57). In 152 (78%) cases, the injury occurred within the city limits, and in 42 (22%) cases it occurred outside the city limits. In 99 (51%) cases, death occurred at the scene before the arrival of emergency services; in 12 (6.2%) cases, death occurred at the scene after the arrival of emergency services; in 8 (4.1%) cases, death occurred in the ambulance on the way to the hospital; in 75 (38.7%) cases, death occurred during hospitalization (fig. 1). In 193 cases, death occurred as a result of blunt injuries and in only 1 case as the result of an acute injury. In 107 cases, the injuries occurred as the result of a road accident, with drivers constituting 22 of the injured, car passengers – 14, motorcyclists – 3, cyclists – 5, pedestrians – 54, and the remaining 9 being other participants of the road traffic. A plane accident caused the deaths of 2 of the injured, 11 died in an accident involving a rail vehicle, and 57 people died as the result of a fall (fall at ground level, fall off of stairs, fall from a height, a dive). Seven accidents were work-related, and the remaining 10 accidents were related to other causes (fig. 2). A NISS score of 0-14 was calculated in 1 case, 15-35 in 35 cases and 36-75 in 158 of analyzed cases. An ISS score of 0-14 was calculated in 4

Fig. 1. Site of death Unauthenticated Download Date | 12/9/16 5:04 PM

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Fig. 2. Type of casualty

assessed cases, 15-35 in 68 cases and 36-75 in 122 cases (fig. 3). A probability of survival (Ps) exceeding 75% was calculated in 19 cases with the use of the TRISS methodology; this constituted 9.8% of all 194 analysed cases, and those cases were considered preventable deaths (NISS 0-14 and/or ISS 0-14 and/or Ps>75%). A preventable death case selected from the cases analyzed using the NISS was also found in the group of such deaths selected with the use of the ISS, and that in turn was found in the group selected using the TRISS. In the group of 19 cases initially assessed as preventable deaths, there were 16 men aged 22-71 (average age 39) and 3 women aged 34-78 (average age 58). 17 cases happened within the city limits, and 2 accidents happened in the countryside. In this group 1 victim was a car driver, 2 were cyclists, 3 were pedestrians, and in 10 cases a fall occurred. All 19 deaths occurred at the hospital. The NISS value in the preventable deaths group was 10-48 (average 24) and the ISS was 9-25 (average 19), while in 10 cases the NISS value equalled the ISS value, and in 9 cases the NISS was higher than the ISS (the difference was 1-32 (average 10). The probability of survival in this group was estimated at 75.599.4% (average 90.9%). Deaths estimated as preventable occurred as a consequence of early (14 cases) or late (5 cases) complications of the injuries. The early consequences were increasing intra-cranial constriction caused by the cranium and brain injuries, internal cerebral haemorrhage (haematocephalus internus) caused by the ha-

emorrhagic injury centre penetrating through into the cerebral ventricular system and posttraumatic shock. These early complications developed in 13 cases as a consequence of cranial and brain injuries or injuries to the cervical part of the vertebral column and spinal cord, and in one case to motor system injuries. The only late complication was in all such cases bronchial pneumonia, which developed during hospital treatment of cranial and brain injuries or injuries to the cervical part of the vertebral column and spinal cord (2 cases) and motor organ injuries (3 cases).

DISCUSSION Assessment of the effectiveness of rescue actions carried out on injury fatalities began

Fig. 3. Severity scores among deceased Unauthenticated Download Date | 12/9/16 5:04 PM

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in the USA in the 1960s. Irregularities in the whole course of the diagnostic-therapeutic process carried out in pre-hospital and hospital conditions were analyzed, and the definition of preventable death and Preventable Death Rate (PDR), representing the percentage of the preventable deaths in the total amount of injury deaths (35), was introduced. In the global literature on the subject, the preventable death rate fluctuates between 4% and 40% (9, 19-27). Lasek et al from Poland conducted research covering 20 years (1977-1996); based on the analysis of 681 traumatic deaths, the preventable death rate was estimated at 11.16%; in the first decade of the analyzed period (1977-1986), the rate amounted to 16.05%, and in the second decade (1987-1996) it was 10.09% (31, 32, 34). The preventable death rate estimated in this study amounted to 9.8%, which lies within the limits estimated by other authors, and compared with the results of Lasek et al confirms a steadily declining tendency. The above result may indicate the progressive improvement in the quality of health care in Poland; however, unequivocal assessment of the situation requires further observation. Probability of survival in the analyzed cases of preventable deaths amounted to an average of 90%, with relatively high ISS values, and often even higher NISS values, which did not accurately predict survival. This state of affairs was a result of an initially good general state of the injured, providing the basis for further analysis of the probability of survival. Over time, however, the condition of the injured deteriorated as a consequence of the gradual increase of the injury effects (e.g., brain oedema, intra-cranial haematoma or post-traumatic shock), which is typical for the progression of such conditions. Meanwhile, the NISS and ISS values were calculated on the basis of the postmortem examinations, which take into account the ultimate injury consequences not present during the initial examination of the injured, and occurring only over time. Similarly, the late complications observed by the authors, such as bronchial pneumonia, are complications typical for the injuries connected with immobilization of the patient during the treatment. Such early and late complications cannot always be prevented, despite appropriate treatment. In the analyzed group, the percentage of prehospital deaths was high and amounted to

61.3%. The authors emphasize that the frequency of pre-hospital deaths depends on the functioning level of the medical rescue system. In Cracow, the percentage is contained within a 50% limit (37); in the research by Mock et al conducted in three large agglomerations in three different countries it amounted to 81% in Kumasi, 72% in Monterrey and 59% in Seattle. Attention should be drawn to the fact that the percentage of such deaths decreases with optimization of treatment of the injured, and may as such be a good indicator of the effectiveness of the medical emergency services in trauma care (38). The probability of survival, calculated or estimated on the basis of the anatomical and physiological injury severity scores, can also be used in the initial assessment of the results of incorrect medical treatment. In individual cases, classification4 of incorrect medical actions has important legal and penal implications; above all, however, it allows assessment of the influence of incorrect medical treatment on the death rate of the victims of accidents. These medical mistakes often gain unjustified media publicity and have a negative influence on the public sense of security. Such analysis, however, requires further research. CONCLUSIONS 1. The preventable death rate from the total number of deaths caused by mechanical injury as the result of an accident was estimated at 9.8%, which represents a result within the broad limits determined on the basis of other research.

4

Polish criminal law does not provide a penalty for the implementation of incorrect medical treatment unless the results of this treatment lead consequence that would not have occurred if the treatment had been correct, e.g., if a death caused by the original injuries was unpreventable, then the doctor (or other qualified health service employee) cannot be brought to justice for the accidental manslaughter, even when the implemented medical treatment was evidently incorrect. However, such a situation does not exclude charging them with the exposure to immediate danger of death or severe impairment of health, as stated in the Polish Penal Code. Unauthenticated Download Date | 12/9/16 5:04 PM

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2. The NISS value in the preventable deaths group amounted to 10-48, whereas the ISS amounted to 9-25; in 10 cases, the NISS value equalled the ISS value, and in 9 cases the NISS was higher than the ISS with the difference of 1-32.

3. The probability of survival in this group of preventable deaths was estimated at 75.599.4%. 4. The preventable deaths occurred as a result of early or late complications of the injuries.

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Pracę nadesłano: 6.11.2007 r. Adres autora: 90-153 Łódź, ul. Kopcińskiego 22

COMMENTARY The Authors present a very important and current issue related to the efficacy of emergency actions in trauma cases, based on an assessment of preventable deaths. The study includes a very large data set: 301 protocols of judicial-medical autopsies of subjects who died as the consequence of an accident. The Authors used objective scales for assessment of injury severity, including anatomical, physiological and anatomophysiological scales, which contributed to high quality of this study. This allowed the reliable assessment of survival probability, and thus the classification of preventable deaths. Detailed assessment of the severity of body injuries is still underused in Poland, which often precludes an objective assessment of the clinical status of the injured, and the ability to effectively compare treatment efficacy between various sites. Thus, the presented study is of great didactic value for physicians who are involved with the everyday task of saving the lives of subjects with trauma. High rates of death at the event site after the trauma, excluding homicide and

suicide, amounting to 51%, before medical rescue team arrived at the event site, draws attention in the study. If the Authors were to present results of detailed analyses of deaths at the event site, especially with regard to the time and extent of bystander first aid and the extent of medical emergency actions, it would allow for a more detailed assessment of the efficacy of conducted medical emergency actions. Here we must emphasize the significant effect of bystander first aid on survival of the injured as a result of trauma. The role of a bystander is to maintain basic life functions until an ambulance arrives, which often takes more than five minutes from circulatory and respiratory arrest. Increased survival in trauma should also be expected to accompany development of Integrated System of Medical Rescue and in the particular level of training of physicians – specialists in emergency medicine and paramedics. Prof. dr hab. Krystyn Sosada Katedra i Oddział Kliniczny Chirurgii Ogólnej i Bariatrycznej i Medycyny Ratunkowej Śl. UM w Katowicach

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