Evaluation of management of road trauma survivors with brain injury and neurologic disability in Victoria.

BACKGROUND: Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999. METHODS: The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records. RESULTS: The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units. CONCLUSION: Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

Road traffic fatalities in Victoria, Australia and changes to the trauma care system.

BACKGROUND: The aim was to identify organizational and clinical errors in the management of road traffic fatalities and to use this information to improve Victoria's trauma care system. METHODS: A multidisciplinary committee evaluated the complete ambulance, hospital and autopsy records of 559 consecutive road traffic fatalities, who were alive on arrival of ambulance services, in five substantial time periods between 1992 and 1998. Patients who survived more than 30 days were excluded. Errors or inadequacies in each phase of management, including those contributing to death, were identified and an assessment was made of the potential preventability of death. RESULTS: Findings between 1992 and 1998 were similar. In 1998, 1672 problems were identified in 110 deaths with 1024 (61 per cent) contributing to death. Eight hundred and forty-two (50 per cent) of the total problems occurred in the emergency department. There were frequent problems in initial patient reception and medical consultation, resuscitation, investigation and assessment (especially of the abdomen and head), and in transfer to the operating theatre or to a higher-level hospital. Victoria's combined preventable and potentially preventable death rate has been unchanged between 1992 and 1998 (34-38 per cent). CONCLUSION: The problems identified led to a Ministerial Taskforce on Trauma and Emergency Services in Victoria as a consequence of which a new trauma system is now being implemented.

Local recurrence after curative anterior resection with principally blunt dissection for carcinoma of the rectum and rectosigmoid.

PURPOSE: The aim of this study was to determine the incidence of local pelvic recurrence of carcinoma of the rectum and rectosigmoid (tumors where the lower edge is 18 cm or less from the anal verge) in a consecutive series of patients operated on by a single surgeon. All patients underwent curative anterior resection and a formal anatomic dissection of the rectum where mobilization was achieved through a principally careful blunt manual technique along fascial planes, preserving an oncologic package. METHOD: During the period April 1986 to December 1997, 157 consecutive anterior resections for carcinoma of the rectum and rectosigmoid were performed by one surgeon (ALP). One hundred thirty-eight (87.9 percent) were curative, and 19 (12.1 percent) were palliative. The mean follow-up period was 46 +/- 31.6 (range, 2-140) months. Data were retrospectively collated and computer coded by an independent contracted medical research team. Follow-up data were available on all patients. RESULTS: Four (3.1 percent) of the 131 patients undergoing curative anterior resection had local recurrence. Local recurrences occurred between 16 and 38 months from the time of resection, and the cumulative risk of developing local recurrence at five years was 5.2 percent. All tumors in which pelvic recurrence occurred were high grade, and the probability of developing local recurrence at five years for this group was 13.9 percent, which is significantly higher compared with patients who had average or low-grade tumors (P = 0.01). The probability of developing local recurrence at five years for Stage I tumors was 0, Stage II was 5.9 percent, and Stage III was 8.9 percent. In addition, there was a significantly higher incidence of local recurrence in the group of patients undergoing ultralow anterior resection (between 3 and 6 cm from the anal verge) as compared with patients undergoing low or high anterior resection (P = 0.03). Local recurrence developed in 3 of 28 (10.7 percent) patients having ultralow anterior resection, 1 of 57 (1.8 percent) patients having low anterior resection (between 6 and 10 cm from the anal verge), and no patients having high anterior resection (above 10 cm from the anal verge). The clinical anastomotic leak rate for curative anterior resection was 7 of 131 patients (5.3 percent). Thirty-seven of the 131 (28.2 percent) required a proximal defunctioning stoma; 35 (41.2 percent) of these were established for low or ultralow anterior resections and 2 for high anterior resection. The overall five-year cancer-specific survival rate of the entire group of 131 patients was 81.8 percent, and the overall probability of being disease free at five years including both local and distal recurrence was 72.9 percent. Three local recurrences occurred in the 101 patients (77 percent) who did not receive any form of adjuvant therapy. One local recurrence occurred in the 18 patients (13.7 percent) who had adjuvant chemoradiation. No recurrence occurred in the 12 patients (9.2 percent) who had adjuvant chemotherapy alone. CONCLUSION: Curative anterior resection for carcinoma of the rectum and rectosigmoid with principally blunt dissection of the rectum in this study is associated with a 3.1 percent incidence and a 5.2 percent probability at five years of developing local recurrence. Evidence from this study indicates that, as with sharp pelvic dissection, a low incidence and probability of local recurrence can be achieved by a principally blunt mobilization technique through careful attention to preservation of fascial planes in the pelvis and removal of an oncologic package with selective rather than routine adjuvant or neoadjuvant chemoradiation.

The preventability of death in road traffic fatalities with head injury in Victoria, Australia. The Consultative Committee on Road Traffic Fatalities.

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) has examined the medical management of patients who died following motor vehicle accidents. Three hundred and fifty-five fatalities with head injury occurring between 1 July, 1992 and 31 December 1997 were assessed by the CCRTF. They represented 79% of the total 449 fatalities examined by the Committee. Following examination of the complete medical records and multidisciplinary discussion, the Committee considered 237 (67%) of the 355 neurotrauma deaths to be non-preventable, 105 (30%) potentially preventable and 13 (4%) preventable. The present analysis excludes the non-preventable deaths in order to focus on preventable factors. Problems identified in the 118 patients pre-hospital included: no intubation; prolonged scene time; and no intravenous access; in 139 emergency room attendances: inappropriate reception including delay in arrival of a consultant, no neurosurgical consultation, no CT scan of the head, inadequate blood gases and oxygen monitoring, inadequate fluid resuscitation, delayed respiratory resuscitation and delayed dispatch to the operating room; in 111 operating room visits: no ICP monitoring, inadequate fluid administration and inappropriate anaesthetic technique; and in 90 intensive care unit admissions: no ICP monitoring. Overall, 1745 individual problems in the various areas of care were identified, of which 1104 (63%) were judged to have contributed to death. Improved delivery and quality of trauma care could reduce the identified problems in emergency services and clinical management. Basic principles of trauma management remain the most important means of reducing morbidity and death following road trauma. The leadership role of the neurosurgeon in neurotrauma care is emphasised.

Consultative Committee on Road Traffic Fatalities: trauma audit methodology.

BACKGROUND: Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria has identified deficiencies and errors in the management of 559 road traffic fatalities in which the patients were alive on arrival of ambulance services. The Committee also assessed the preventability of deaths. Reproducibility of results using its methodology has been shown to be statistically significant. The Committee's findings and recommendations, the latter made in association with the learned Colleges and specialist Societies, led to the establishment of a Ministerial Taskforce on Trauma and Emergency Services. As a consequence, in 2000, a new trauma care system will be implemented in Victoria. This paper presents a case example demonstrating the Committee's methodology. METHODS: The Committee has two 12 member multidisciplinary evaluative panels. A retrospective evaluation was made of the complete ambulance, hospital and autopsy records of eligible fatalities. The clinical and pathological findings were analysed using a comprehensive data proforma, a narrative summary and the complete records. Resulting multidisciplinary discussion problems were identified and the potential preventability of death was assessed. RESULTS: In the present case example the Committee identified 16 management deficiencies of which 11 were assessed as having contributed to the patient's death; the death, however, was judged to be non-preventable. CONCLUSION: The presentation of this example demonstrating the Committee's methodology may be of assistance to hospital medical staff undertaking their own major trauma audit.

Management of severe trauma in intensive care units and surgical wards.

OBJECTIVE: To evaluate the management of severe trauma in intensive care, high dependency and general surgical wards of Victorian hospitals. DESIGN: Retrospective case review by multidisciplinary committees. SUBJECTS: The first 256 people who died from road traffic accidents who were alive on the arrival of emergency services between 1 July 1992 and 30 June 1994. MAIN OUTCOME MEASURES: (1) Severity of injury according to clinical diagnosis, autopsy findings and recognised trauma-scoring methods; (2) errors in management, identified as contributing or not contributing to the cause of death, and categorised as "management", "system", "diagnostic" or "technique" errors. RESULTS: Most patients (61%) were admitted to an intensive care unit (ICU), and 19.5% were admitted to high dependency or general surgical wards. Of 2187 errors of care identified, 11.8% occurred in ICU and 6.7% in wards, with the remainder occurring during the earlier phases of care. Most errors were classified as management errors (82% of ICU errors and 88% of ward errors). Fifty-two per cent of ICU errors and 71% of ward errors were judged to contribute to the patient's death. CONCLUSIONS: A significant number of errors of trauma management occur in the intensive care and general surgical ward. Improvement in late trauma care may reduce the number of preventable trauma deaths.

Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria.

OBJECTIVES: Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria. METHODS: Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals. RESULTS: Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1*; metropolitan, 3.1* and 1.6*; large regional, 3.8* and 1.8*; small regional, 5.1* and 2.6*) (*p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40%*; metropolitan, 41%*; large regional, 53%*; small regional, 62%*) (*p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified. CONCLUSION: Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria.

BACKGROUND: Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified problems in the management of traffic fatalities. Its two evaluative committees have additionally assessed the potential preventability of death. Previous studies have shown only poor to fair reproducibility of death judgments. METHODS: Problems in the management of 60 consecutive road traffic fatalities and the potential preventability of death were independently evaluated by the two committees. Inter-rater and inter-committee concordance were analyzed using the kappa statistic. RESULTS: Reproducibility was high. Inter-committee agreement on nonpreventable, potentially preventable, and preventable death judgments was high (kappa = 0.73, 95% confidence interval = 0.57-0.89). Agreement within the two evaluative committees was also high (average weighted kappa = 0.73 and 0.74). There was good agreement between committees on problems identified, including those contributing to death. CONCLUSION: The high kappa concordance on preventable death judgments and the agreement on problem identification supports the reproducibility of the methodology used.

Management deficiencies and death preventability in 120 Victorian road fatalities (1993-1994). The Consultative Committee on Road Traffic Fatalities in Victoria.

BACKGROUND: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: survival probability between 25 and 75%). METHODS: For 1993-94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre-hospital, hospital and autopsy records. RESULTS: A total of 1175 problems were identified in 455 admission to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre-hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre-hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non-preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable. CONCLUSIONS: Organization and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.

Evaluation of the medical management and preventability of death in 137 road traffic fatalities in Victoria, Australia: an overview. Consultative Committee on Road Traffic Fatalities in Victoria.

OBJECTIVES: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: 25 to 75%). METHODS: For 1992 and 1993 all 137 fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete prehospital, hospital, and autopsy records. RESULTS: 1,012 problems were identified in 509 admissions to the various areas of care. Six hundred eighty-five (68%) were management errors and 217 (21%) were system inadequacies. Technique errors (45 (4%)), diagnosis delays (25 (2%)), and diagnosis errors (40 (4%)) were less frequent. The emergency department (ED) accounted for 537 (53%) problems, followed by prehospital (200 (20%)) and intensive care unit (118 (12%)). Four hundred seventy (46%) problems were assessed as contributing to death. Two hundred twenty-eight (49%) occurred in the ED, 90 (19%) were prehospital problems, and 63 (13%) occurred in the intensive care unit. Management errors comprised 326 (69%) problems contributing to death, and system inadequacies 88 (19%). Resuscitation problems accounted for 82 (49%) of the 167 ED management errors contributing to death. Eighty-five (62%) deaths were assessed as nonpreventable, 7 (5%) as preventable, and 45 (33%) as potentially preventable. CONCLUSION: Organizational and educational counter measures are required to reduce the high frequency of problems in emergency services and clinical management.