Multiinstitutional experience with the management of superior mesenteric artery injuries.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

The effects of pressure control versus volume control assisted ventilation on patient work of breathing in acute lung injury and acute respiratory distress syndrome.

BACKGROUND: Patient work of breathing (WOB) during assisted ventilation is reduced when inspiratory flow (V(I)) from the ventilator exceeds patient flow demand. Patients in acute respiratory failure often have unstable breathing patterns and their requirements for V(I) may change from breath to breath. Volume control ventilation (VCV) traditionally incorporates a pre-set ventilator V(I) that remains constant even under conditions of changing patient flow demand. In contrast, pressure control ventilation (PCV) incorporates a variable decelerating flow wave form with a high ventilator V(I) as inspiration commences. We compared the effects of flow patterns on assisted WOB during VCV and PCV. METHODS: WOB was measured with a BICORE CP-100 monitor (incorporating a Campbell Diagram) in a prospective, randomized cross-over study of 18 mechanically ventilated adult patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Tidal volume, inspiratory time, and mean ventilator V(I) were constant in each mode. RESULTS: At comparable levels of respiratory drive and minute ventilation, patient WOB was significantly lower with PCV than with VCV (0.59 +/- 0.42 J/L vs 0.70 +/- 0.58 J/L, respectively, p < 0.05). Ventilator peak V(I) was significantly higher with PCV than with VCV (103.2 +/- 22.8 L/min vs 43.8 L/min, respectively, p < 0.01). CONCLUSIONS: In the setting of ALI and ARDS, PCV significantly reduced patient WOB relative to VCV. The decrease in patient WOB was attributed to the higher ventilator peak V(I) of PCV.

Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients.

OBJECTIVES: First, to determine whether the severity of shock, as measured by systemic hypotension and metabolic acidosis, is significantly associated with a higher risk of acute lung injury in patients with severe trauma. Second, to determine whether the volumes of blood and crystalloid solutions administered in the early posttrauma period are independent risk factors for acute lung injury in severely traumatized patients. DESIGN: Prospective observational study. SETTING: Level I urban trauma center in a university hospital. PATIENTS: A total of 102 severely injured, mechanically ventilated trauma patients with an Injury Severity Score > or =16 and aged between 18 and 75 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Initial clinical and laboratory data were collected in the emergency department, and on a daily basis thereafter during the patient's intensive care unit stay. Of the 102 severely injured patients enrolled, 42 developed acute lung injury (41%) and 60 did not (59%). A total of 93% of the trauma patients who developed acute lung injury during the 17-month study period were included in the study. Initial base deficit was significantly lower in patients who developed acute lung injury than in those who did not (-8.8+/-4.5 vs. -5.6+/-5.1, p<.01). The difference in systolic blood pressure between the two groups was not significant. CONCLUSIONS: In this group of severely injured trauma patients, the degree of metabolic acidosis at the time of admission identified those patients with the highest probability of developing acute lung injury. In addition, the volume of crystalloid solution administered during the first 24 hrs was significantly greater in patients who later developed acute lung injury. Finally, there was a significantly higher morbidity in patients who developed acute lung injury, whereas mortality did not differ between the two groups.

Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma.

BACKGROUND: The detection of isolated intestinal injuries after blunt trauma can be difficult because of subtle signs and symptoms, often leading to delayed diagnosis. We hypothesized that specific clinical indicators could be identified to assist in the diagnosis of these injuries. METHODS: Medical records of all patients with such injuries from 1988 to 1996 were reviewed. The patients were stratified into those operated on within 6 hours of presentation (apparent injury) and those operated on after 6 hours (occult injury), and the data were compared. RESULTS: Forty-six patients with isolated intestinal injuries were identified. There were no differences in the rate of peritonitis or free fluid on abdominal computed tomography, blood loss, intraoperative findings, or morbidity and mortality between groups. Leukocytosis (sensitivity, 84.8%; specificity, 55.2%; p = 0.01) and free fluid on computed tomography were frequently present, however, and their significance was underappreciated in the occult injury group. CONCLUSION: After blunt abdominal trauma in patients without obvious indications for invasive evaluation of the abdomen (e.g., peritoneal lavage, laparoscopy, laparotomy), leukocytosis can indicate an intestinal injury. Additionally, unexplained free fluid on abdominal computed tomography must be aggressively evaluated.

Trauma deaths in a mature urban vs rural trauma system. A comparison.

OBJECTIVE: To compare the timing, severity, and injury characteristics of patients dying from trauma in an urban vs a rural setting. DESIGN: Retrospective review of autopsy database (urban) and medical examiner database (rural), with selected medical chart review. SETTING: An organized urban trauma system with 6 trauma centers and a rural state with no formal trauma system and 1 trauma center. PATIENTS: All trauma fatalities occurring in an urban (n = 612) and a rural (n = 143) setting during a 1-year period. RESULTS: In the urban system, 248 patients (40.5%) died at the scene of injury compared with 103 (72%) patients in a rural environment. During the first 24 hours of hospitalization 243 (39.7%) urban patients died compared with 23 (16%) rural patients. Eighty-nine urban patients (14.5%) and 17 rural patients (11.8%) survived for more than 24 hours but later died in the hospital. The mean age of those who died was significantly greater in the rural trauma system than in the urban trauma system (P < .001), and the Injury Severity Score was significantly less in the rural trauma system than in the urban trauma system (P < .01). In the patients who died after being admitted to the hospital for more than 24 hours there was a significantly higher rate of preexisting comorbidity in the rural patients than in the urban patients (P < .05). The most frequent cause of death in the rural setting was multisystem organ failure; head injury was the most common cause of death in the urban setting. CONCLUSIONS: Patients who die in a rural area without a formal trauma system are more likely to die at the scene, are less severely injured, and are older. Rural trauma patients who are admitted to a hospital and who survived for at least 24 hours before dying are older, less severely injured, have significantly more comorbidities, and are more likely to die of multisystem organ dysfunction than their urban counterparts. These differences reflect the different patient populations and injury patterns that confront urban and rural trauma centers. The higher proportion of scene deaths in the rural environment may reflect the longer discovery and transport times that occur in a rural setting.

Use of tissue oxygen tension measurements during resuscitation from hemorrhagic shock.

BACKGROUND: Tissue oxygen tension can be measured directly in selected organ beds, and these measurements may be more sensitive in assessing the adequacy of resuscitation than global physiologic parameters. We hypothesized that heart tissue oxygen tension would be an important marker for the severity of ischemic insult to the heart during hemorrhagic shock. We further hypothesized that gut oxygen tension measured in the jejunum would prove to be a better measure of splanchnic hypoperfusion than intramucosal pH (pHi). METHODS: Tissue oxygen probes were inserted directly into the myocardium of the left ventricle and into the lumen of the proximal jejunum in 10 anesthetized swine. A pHi catheter was introduced into the stomach. The animals were subjected to a controlled hemorrhage of 50% of estimated blood volume. Gut and cardiac oxygen were monitored continuously during hemorrhage and resuscitation, which was performed with shed blood and crystalloid. RESULTS: While gut O2 and pHi trended together, we were unable to establish a correlation between changes in these two variables during hemorrhage and resuscitation. Heart PO2 decreased significantly during hemorrhage, but surpassed baseline values after resuscitation, a finding not seen in gut PO2. No standard physiologic variables reliably predicted changes in heart PO2 during these experiments. CONCLUSIONS: Tissue oxygen tensions measurements are highly responsive to changes induced during graded hemorrhagic shock and resuscitation. Gut PO2 and pHi appear to be measuring different physiologic processes in the gastrointestinal tract. The compensatory ability of the heart far exceeds that of the gut after ischemic insult. This hemorrhagic shock model appears feasible for the study of various methods of resuscitation.

Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT.

OBJECTIVE: The purpose of this study was to determine the diagnostic sensitivity and specificity of CT in detecting acute rupture of the diaphragm after blunt trauma. MATERIALS AND METHODS: Abdominal CT scans taken before surgery of 11 patients with diaphragmatic rupture (eight left and three right) and 21 patients with intact diaphragms after major acute blunt abdominal trauma were independently reviewed by three observers who were unaware of surgical findings. Retrospective note was made of diaphragmatic discontinuity, intrathoracic herniation of abdominal contents, waistlike constriction of bowel ("collar sign"), and associated findings. Right and left hemidiaphragms were graded as intact or ruptured, and these findings were correlated with surgical findings. Individual and average observer sensitivity and specificity in detecting acute diaphragmatic rupture were calculated. RESULTS: Of the 11 cases of diaphragmatic rupture, diaphragmatic discontinuity was seen in eight, visceral herniation was seen in six, and the "collar sign" was seen in four cases. Hemoperitoneum of hemothorax completely obscured visualization of the ruptured diaphragm in three cases. Individual diagnostic sensitivity for detecting diaphragmatic rupture was 54-73% and specificity was 86-90%. Average sensitivity for the three observers was 61% (95% confidence interval, 41-81%), and average specificity was 87% (95% confidence interval, 76-99%). CONCLUSION: CT is highly specific in diagnosing acute diaphragmatic rupture and detects approximately two thirds of acute diaphragmatic ruptures after blunt trauma.

Violence prevention involvement among trauma surgeons: description and preliminary evaluation.

UNLABELLED: Violence has become a primary focus for the national agenda and a growing public health concern in the medical community. Although prevention is a major component of public health policy, it is unclear what contribution trauma surgeons and trauma centers are making toward violence prevention. PURPOSE: The purpose of this study was to assess the extent of violence prevention activity at trauma centers, the involvement and attitudes of trauma surgeons toward violence prevention, and the perceived need for a formal violence prevention curriculum. METHODS: Self-report postal surveys were sent to trauma directors and associate directors at 430 Level I and Level II trauma centers throughout the United States. A descriptive analysis was performed using the 230 (53%) returns. RESULTS: 55% of Centers reported an active violence prevention program with surgeons participating in these existing programs 47% of the time. Overall, only 26% of surgeons reported being active in violence prevention activities, although 71% thought that violence prevention should be an integral part of trauma center activity. Trauma surgeon involvement in violence prevention and the presence of an active institutional program was demonstrated significantly (p <0.001, chi2). Lack of available time and "not knowing where to start" were cited as the most common reasons for lack of involvement in violence prevention activity. CONCLUSION: There is strong support among trauma surgeons for violence prevention programs and for the integration of these programs into the trauma center. A relatively small number of surgeons actually are engaged in violence prevention activity, but most (69%) are willing to become personally involved. The data suggest that established violence prevention programs facilitate involvement of trauma surgeons in violence prevention activity. The discrepancy between actual involvement in, and general support for, violence prevention efforts may be explained by a lack of established roles and previous experience for surgeons and by limited guidance outside of existing programs.

Risks, costs, and the expected complication of re-injury.

BACKGROUND: The purpose of this study was to determine the characteristics of young victims of violence and the risk of rehospitalization due to intentional injury (recidivism) and to estimate the potential cost of these injuries. MATERIALS AND METHODS: Trauma admissions from January 1, 1991 to December 31, 1993, at San Francisco General Hospital of youths < 25 years old who were victims of gunshot wounds (GSWs), assault, and stab wounds were screened. Five hundred and fifty-two charts were reviewed after sampling every other chart. The cost of hospitalization was estimated from the Medicare charge-to-cost ratio. RESULTS: There were 87 (16%) persons who had a prior injury, of whom 82 (94%) had suffered their injury within the previous 5 years. The predominate mechanism of injury was GSW (242, 44%). There were 38 deaths; 35 (92%) were by firearms. The estimated cost of hospitalization for 552 youths for 3 years was $3,843,545.58. CONCLUSIONS: Intentional injury is a major risk factor and potential predictor for re-injury. Firearms are a major mechanism of intentional injury among youths and a major determinate of death. With the estimated cost of $2,562,363.72 per year for all youths at our hospital, intentional injury is a major health care issue for youths and hospitals.

Neurogenic pulmonary edema in fatal and nonfatal head injuries.

Impaired pulmonary function is a frequent but poorly understood complication of acute head injury (HI). A potential early contributor to the pulmonary dysfunction seen in HI patients is neurogenic pulmonary edema (NPE). We hypothesized that NPE would occur early after HI and that it would have a continuum of clinical severity depending on the severity of the HI and associated intracranial hypertension. A large autopsy data base and inpatient HI data base were used to search for cases of NPE. Patients in the autopsy data base were stratified according to injury type and whether they died at the scene or within 96 hours of injury. There were significant (p < 0.0001, analysis of variance) elevations in lung weights in patients dying at the scene and within 96 hours from HI, compared with those dying from other noncentral nervous system injuries. No other organs studied showed significant weight increases. The incidence of NPE in isolated HI patients dying at the scene was 32%. In patients with isolated HI dying within 96 hours, the incidence of NPE was 50%. We found an inverse correlation (r = 0.62; p < 0.0014) between the initial cerebral perfusion pressure and the PaO2/FIO2 ratio despite a normal-appearing chest x-ray film. We conclude that NPE occurs frequently in HI patients. The process of edema formation begins early in the clinical course and is isolated to the lung.(ABSTRACT TRUNCATED AT 250 WORDS)

High-risk behavior and the public burden for funding the costs of acute injury.

OBJECTIVE: To determine if high-risk behavior is associated with increased injury severity and cost and if public agencies bear a disproportionate burden of that cost. DESIGN: Case comparison study utilizing patient data collected over a 10-year period. SETTING: Five level 1 and 2 trauma centers in an urban-suburban community with a population of 2.4 million. PARTICIPANTS: Trauma registry data from 37,304 consecutive hospitalized adult patients with trauma. Financial data were reported and analyzed on 28,842 of these. MAIN OUTCOME MEASURES: Incidence of alcohol intoxication, other drug use, use of vehicular protective devices, and firearm violence injuries in patients with private vs public health care sponsorship. Length of hospital stay, injury severity, and hospital unit charges were assessed for high-risk behavior. RESULTS: High-risk behavior was more prevalent among trauma patients relying on public funding to cover the costs of their injuries (P < .001). Total hospital unit charges were 28% and 35% higher for motorists not wearing seat belts and motorcyclists not wearing helmets, respectively. Injury severity and length of stay were also higher (P < .001). CONCLUSIONS: High-risk behavior is associated with increased injury severity and cost. Trauma victims exhibiting high-risk behavior more often depend on public agencies to cover the cost of acute injury. Failure to establish and enforce laws and policies designed to reduce or prevent injury may generate enormous trauma care costs, borne to a large extent by public agencies. Further restriction of certain types of high-risk behavior and the institution of "users' fees," taxes, or penalties may be necessary to reduce the disproportionate public agency cost generated by this activity.

Randomized study of algorithms for discontinuing tube thoracostomy drainage.

BACKGROUND: The optimal method for removal of chest tubes has not been determined and opinion remains divided. The purpose of this study was to determine the difference between two algorithms for the removal of chest tubes: one with continuous negative intrathoracic pressure (suction group) and the other with a trial of water seal (water-seal group). STUDY DESIGN: This study was a prospective randomized trial of 80 trauma patients requiring tube thoracostomies. RESULTS: Both methods of chest tube removal had similar incidences of recurrent pneumothorax (2.5 percent). The suction group had a shorter total chest tube time (72.2 hours versus 92.5 hours, p = 0.013) and shorter time required to remove the chest tube following air leak resolution (25.2 hours versus 35.6 hours, p = 0.034). Additionally, there were more patients requiring prolonged (greater than 36 hours) removal times in the water-seal group (p = 0.009). CONCLUSIONS: Both suction and water-seal methods for chest tube removal are effective and have similar incidences of recurrent pneumothorax. The use of the suction algorithm significantly decreased both chest tube duration and the time taken for chest tube removal. In patients hospitalized for isolated pneumo- or hemothorax, the use of the suction algorithm potentially could lead to shorter length of stay.

Differential clearance of colloid and crystalloid solutions from the lung.

The hypothesis that alveolar fluid clearance depends on factors other than the alveolar-capillary oncotic gradient was tested by comparing lung clearance rates of three different colloid solutions and isotonic saline. The solutions (4 mL/kg) were instilled into the lower lobes of New Zealand rabbits. Colloid solutions were diluted to produce a fixed gradient of 8 mm Hg for each experiment. Fluid clearance was calculated at 3 hours, using lung gravimetrics. Surface tension, as a measure of surfactant inhibition, was measured in separate experiments using bubble surfactometry. Airway inflammatory reaction was assessed by determining leukocyte counts in bronchoalveolar lavage (BAL). Data were analyzed using ANOVA with Tukey's test for multiple comparisons. Alveolar fluid clearance rates were significantly different (p < 0.01) between groups, and varied between 2.0 +/- 0.12 mL/kg (saline), and -0.04 +/- 1.7 (plasma). Clearance rates for saline and dextran 70 were similar despite an increased plasma-alveolar osmotic gradient. Surface tension, reflecting surfactant inhibition, was greater with the plasma (3.9 +/- 3.7 mN/m) compared with the other groups (range, 0.23-0.48 mN/m) (p < 0.01). Neutrophil migration was greater with the protein group, but there were no differences in total WBC counts between groups. These data suggest that fluid clearance from the airspaces is primarily dependent on factors other than simple colloid-capillary osmotic gradient. Alveolar PMN migration was not a major determinant of fluid clearance. The association between surfactant inhibition and decreased fluid clearance rate observed with homologous plasma suggests that protein interference with the surfactant monolayer may play a role in reducing alveolar fluid clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of traumatic death. A population-based analysis.

Despite the proliferation of trauma systems, there are no population-based data describing the epidemiology of traumatic death. To provide these data, we reviewed all trauma deaths occurring in San Diego (California) County during 1 year. There were 625 traumatic deaths during the study (27.3 deaths per 100,000 population per year). Motor vehicle trauma was the most common cause of injury leading to death (N = 344 [55.2%]; 15.0 annual deaths per 100,000 population). Central nervous system injuries were the most common cause of death (48.5%, or 13.2 deaths per 100,000 population per year). Sepsis was responsible for only 2.5% of the overall mortality. Based on life-table data, traumatic death resulted in an annual loss of 1091 years of life per 100,000 and an annual loss of 492 years of productivity per 100,000. Injury continues to account for an enormous loss of life despite improvements in survival wrought by trauma systems.

The etiology of missed cervical spine injuries.

Missed or delayed diagnosis of cervical spine (C-spine) injuries may lead to extension of those injuries and subsequent preventable mortality or morbidity. Previous reports examining the incidence of missed C-spine injuries have not determined the nature of the causal clinical errors made or the extent to which these errors are avoidable. This study was undertaken to (1) determine the incidence of delayed or missed diagnosis of C-spine injuries and the consequences of those missed injuries; (2) define the clinical errors leading to the delays; and (3) to determine if these errors are the result of fundamental problems or a lack of advanced diagnostic skills or equipment. Between August 1985 and February 1991, 32,117 trauma patients were admitted to one of the six trauma centers in San Diego county. Cervical spine injuries were identified in 740 patients and the diagnosis was delayed or missed in 34 patients (4.6%). Ten of the 34 patients (29%) developed permanent sequelae as a result of these delays. The single most common error was the failure to obtain an adequate series of C-spine roentgenograms. Delayed diagnosis could have been avoided in at least 31 of 34 injuries by the appropriate use of a standard three-view C-spine series and careful interpretation of those roentgenograms. Patients at risk for C-spine injuries require a technically adequate three-view C-spine series and skilled radiographic interpretation. Cervical spine precautions should be maintained, particularly in high risk patients, until appropriate and expert review of the cervical spine roentgenograms can be obtained.

An evaluation of provider-related and disease-related morbidity in a level I university trauma service: directions for quality improvement.

As the number of preventable trauma-related deaths plateaus as a result of trauma system development, new directions for quality improvement in trauma care must come from analyzing morbidity with standardized methods to establish thresholds for provider-related and disease-specific complications. To establish such thresholds and determine priorities for improvements in quality all trauma patients who died, who were admitted to the ICU or OR, who were hospitalized for more than 3 days, or who were interfacility transfers to an academic trauma service, were concurrently evaluated for 1 year. All complication events were defined, reviewed, tabulated, and classified using 135 categories of complications. These categories were subdivided into provider-specific and disease-specific complications. Provider-related complications were classified as justified or unjustified to allow identification of events with a potential for improvement. A total of 1108 patients were admitted (mean ISS, 17); there were 97 deaths. Three potentially preventable deaths were identified, 857 complication events were identified, and 285 provider-related complications were responsible for errors with potential for improvement in 59 events (21%). Disease-specific morbidity was primarily related to infection; pneumonia accounted for 36% of all infectious complications and systemic infection for only 8.6% of infectious complications. Organ failure and other major systemic complications occurred in 2%-8% of patients. This type of analysis forms the basis on which to determine thresholds of provider-specific and disease-specific morbidity in a trauma hospital and serves as a guide to direct efforts toward continuous quality improvement.

An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement.

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.