World J Surg (2014) 38:3125–3132 DOI 10.1007/s00268-014-2755-0
ORIGINAL SCIENTIFIC REPORT
Preventable and Potentially Preventable Deaths in Severely Injured Elderly Patients: A Single-Center Retrospective Data Analysis of a German Trauma Center Carsten Schoeneberg • Marc Schilling Thomas Probst • Sven Lendemans
•
Published online: 29 August 2014 Socie´te´ Internationale de Chirurgie 2014
Abstract Background Due to widespread demographic changes, populations in industrial countries are ageing. A common tool for quality improvement of trauma care is the analysis of deaths in trauma patients. This study focuses on preventable or potentially preventable deaths, and on patterns of errors in severely injured elderly patients, a group that is under-represented in the literature. Methods Data from a level 1 trauma center in Germany were analyzed for this study. A retrospective chart analysis was performed for all deceased patients older than 75 years with an Injury Severity Score greater than 15. Additionally, the data from the Trauma Registry of the German Society for Trauma Surgery were used. According to a Trauma Division Morbidity and Mortality conference, and after a review of all authors, deaths were classified as preventable, potentially preventable, and non-preventable. Results Of the 2,304 patients admitted to the trauma room, 108 met the inclusion criteria. A total of 62 (57.41 %) patients died. Two deaths were declared as preventable deaths (3.23 %) and eight as potentially preventable (12.90 %). The most common preclinical error was associated with airway management. Hemorrhage control was the leading error in the clinical setting. Excessive fluid volume resuscitation was the second most common error detected. Conclusion The rate of preventable or potentially preventable deaths in severely injured elderly patients is similar to that reported for other age groups. Thus, most errors were human judgment errors or human treatment errors; therefore, education and training in the treatment of severely injured patients is extremely important.
C. Schoeneberg (&) M. Schilling S. Lendemans Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany e-mail: [email protected] M. Schilling e-mail: [email protected] S. Lendemans e-mail: [email protected] T. Probst Department of Trauma, Orthopedic, and Hand Surgery, Municial Hospital Neuss, Lukashospital GmbH, Neuss, Germany e-mail: [email protected]
Abbreviations AIS Abbreviated Injury Scale bpm Beats per minute CT Computed tomography DGU German Society for Trauma Surgery EMS Emergency medical system GCS Glasgow Coma Scale Hb Hemoglobin ICU Intensive care unit ISS Injury Severity Score M&M Morbidity and mortality conference MOF Multi-organ failure RISC Revised injury severity classification
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SPSS TRISS
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Statistical Package for the Social Sciences Trauma and Injury Severity Score
Introduction It is widely known that the population of industrial countries is ageing considerably. For example, in 2011, a total of 21 % of the German population was older than 65 years, compared with 15 % in 1990. This is the highest rate in the EU [1]. Age is a commonly known risk factor for mortality after trauma [2]. Elderly patients also require a higher amount of hospital resources after trauma than do younger patients [3, 4]. However, with an Injury Severity Score (ISS) greater than 30, the length of intensive care unit (ICU) stay is shorter due to increased mortality [3]. Elderly patients often present comorbid conditions, concomitant medication such as anticoagulation drugs, and a decreased physiologic reserve. Therefore, the ability to respond to trauma resuscitation and the impact of the injuries itself is decreased compared with younger patients [5]. Because of medication, the response after hemodynamic shock can be different from that in younger populations with the absence of hypotension and tachycardia [6]. Therefore, the injury severity and the response to resuscitation can be underestimated [7, 8]. A literature research found only a single publication investigating preventable deaths in geriatric trauma patients. This study was published in 1992, and all trauma patients aged over 65 years were included. The authors reported that the decedents were older (77.6 ± 1.5 vs. 74.6 ± 0.4 years) and more severely injured (ISS 23.3 ± 2.7 vs. 8.5 ± 0.5) [9]. The research presented in this study investigates preventable and potentially preventable deaths in severely injured elderly patients. Additionally, any corresponding errors were analyzed. To anticipate the demographic changes and to accommodate the results of Pellicane et al. [9], this study focuses on patients older than 75 years with an ISS greater than 15. To the best of our knowledge, this is the first study to investigate these patients.
Materials and methods This study analyzed data from a level 1 trauma center in Germany. The data were collected prospectively for the national trauma registry, called the Trauma Registry of the German Society for Trauma Surgery (DGU). Data from the Trauma Registry of the DGU have received full approval from the Ethics Committee of the University of
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Witten/Herdecke in Cologne, Germany. As the trauma registry of the DGU is an anonymous register, the Institution Review Board waived the need for patient consent. Hospital records of the patients were also retrospectively analyzed. This study also received approval from the Ethics Committee of the University of Duisburg-Essen in Essen, Germany. The following inclusion criteria were applied: primary admission to the hospital; ISS score C16; C76 years of age; admission occurred between July 2002 and December 2011. Preventable and potentially preventable deaths During a monthly Trauma Division Morbidity and Mortality (M&M) conference, all traumatic deaths are reviewed and classified as preventable, potentially preventable, and non-preventable. This classification was analyzed for a second time by every author on its own. When opinions differed, the case was discussed until a final decision was made. All available clinical patient data, including the pre-hospital emergency physician notes, trauma room documentation, surgery reports, imaging, electronic labs, documentation for the Trauma Registry of the DGU, and in-patient chart were reviewed. MacKenzie published three criteria for a potentially preventable death: the injury must be survivable, the delivery of care is suboptimal, and the error in care must be directly or indirectly implicated in the death of the patient [10]. Shackford et al. [11] defined preventability as follows: ‘‘(1) Anatomic injury or combination of injury considered survivable; (2) Physiologic state at time of arrival of first responder critical to judgment of preventability; patient generally stable; if unstable patient becomes stable with treatment; (3) Evaluation and management suspect in any way.’’ Patterns of errors Errors occurring in the treatment were defined by Reason [12] as ‘‘the failure of a planned action to achieve its desired goal.’’ The recommendations of the DGU Guideline on Treatment of Patients with Severe and Multiple Injuries [13] and the European guideline Management of Bleeding and Coagulopathy Following Major Trauma were used to decide whether or not an error occurred. In detail, the recommendations for pre-clinical airway management are as follows: • •
Multiply injured patients with apnea or gasping must be intubated and ventilated. Multiply injured patients should be intubated and ventilated at the preclinical stage with the following indications:
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• • • •
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hypoxia despite oxygen administration severe craniocerebral trauma with a Glasgow Coma Scale (GCS) \9 trauma-associated hemodynamic instability (systolic blood pressure \90 mmHg) severe chest trauma with respiratory failure.
Trauma admissions 2,304
> 75 years 258
Examples from the recommendations of the European guideline Management of Bleeding and Coagulopathy Following Major Trauma [14] are as follows: •
•
‘‘We recommend that tranexamic acid be administered as early as possible to the trauma patient who is bleeding or at risk of significant hemorrhage at a loading dose of 1 g infused over 10 min, followed by an intravenous infusion of 1 g over 8 h’’ ‘‘We recommend the early use of prothrombin complex concentrate (PCC) for the emergency reversal of vitamin K-dependent oral anticoagulants.’’
The average time of all treated patients in our hospital was used to judge errors in time periods. This resulted in an average time for preclinical rescue of 45 min, for trauma room treatment of 30 min, and for the first emergency surgery of 120 min [15]. In the same study, a higher rate of mortality, among other factors, was associated with prolongation of these time periods [15]. Data were analyzed using the Statistical Package for the Social Sciences, version 21 (IBM, Armonk, NY, USA).
Results Within the observation period, 2,304 patients were admitted to the trauma room. Of these, 258 patients were older than 75 years. A total of 108 patients met the inclusion criteria. The mean GCS was 8.06, the mean ISS was 28.45, the mean Abbreviated Injury Scale (AIS) head was 4.01, and the mean age was 82.2 years. A total of 38.3 % were male patients. A total of 62 patients died after trauma, resulting in a mortality rate of 57.41 %. The expected mortality rate, demonstrated by the Revised Injury Severity Classification (RISC), was 54.55 %. After the M&M conference and author review, two deaths were classified as preventable (3.23 % of deaths, 1.85 % of admissions) and eight deaths as potentially preventable (12.90 % of deaths, 7.41 % of admissions) (Fig. 1). Preventable deaths Both preventable deaths exhibited an accumulation of avoidable errors. The general patients’ data are shown in Table 1. Both patients were intubated although the GCS was 15 at the accident scene. Patient 1 was involved in a traffic
Met inclusion criteria 108
Nonpreventable 98 (90.74%)
Deaths
Survivors
62 (57.41%)
46 (42.59%)
Potentially preventable
Preventable 2 (3.23%)
8 (12.90%)
Fig. 1 Trauma deaths 2002–2011
Table 1 General data for patients whose deaths were preventable Age
ISS
RISC
GCS
AIS head
Sex
Patient 1
76
41
50.8
15
0
Male
Patient 2
83
35
53.5
15
0
Female
AIS Abbreviated Injury Scale, GCS Glasgow Coma Scale, ISS Injury Severity Score, RISC Revised Injury Severity Classification
accident. He suffered a fracture of the femur, a stable fracture of cervical vertebras 3 and 6, and an unstable fracture of the thoracic vertebra 8 without spinal cord injury. In total, 2,500 ml of fluid volume was infused preclinic and at admission. Because of concomitant medication with phenprocoumon, the coagulation status of the patient was abnormal. There was no response in treatment over several days. After extubation, the patient suffered from a drop of oxygen saturation, most likely because of respirator-associated pneumonia, and re-intubation was necessary. After 31 days, the patient died after suffering septic shock. The second patient was involved in a vehicle accident, and suffered open fractures of lower limbs, a tension pneumothorax, and a minor injury to the soft tissue of the elbow. Aspiration occurred during pre-clinical intubation. A total of 3,000 ml fluid volume was infused. A thoracic drainage treating the tension pneumothorax was placed after computed tomography (CT) scans approximately 45 min after arrival at the hospital. Because of the open fractures, the patient underwent emergency surgery, which
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Table 2 General data of patients whose deaths were potentially preventable Patient
GCS
ISS
RISC
AIS head
AIS neck
AIS thorax
AIS abdomen
AIS extremities
AIS skin
Age
1
12
16
38.9
4
0
0
0
0
0
83
2
6
29
79.1
0
2
0
3
4
0
87
3
15
41
86.4
0
0
0
5
4
0
78
4
14
33
65.7
0
0
5
0
2
2
76
5
9
19
13.1
0
0
3
0
3
1
92
6
3
57
87.9
5
2
4
0
4
3
84
7
3
24
67.5
4
2
2
0
0
1
90
8
10
20
27.5
4
0
0
0
2
0
83
AIS Abbreviated Injury Scale, GCS Glasgow Coma Scale, ISS Injury Severity Score, RISC Revised Injury Severity Classification
lasted 201 min. Although, coagulation was abnormal, the patient was treated with heparin. After 7 days, the patient died, suffering from multi-organ failure (MOF).
Patterns of errors in the decedents
Potentially preventable deaths
The preclinical rescue time was exceeded in 11 patients, with a range of 33–114 min. In 11 cases, the infused fluid volume was more than 1,500 ml (Fig. 2). A total of 15 errors occurred with regard to airway management in 13 patients: impossibility of securing the airway (one), re-intubation because of malposition (two), unilateral intubation (three), not indicated intubation (three), no intubation, although it was indicated (three), and aspiration (three). In seven cases, an indicated thoracic drain was not established.
The patient characteristics of the potentially preventable deaths are shown in Table 2. Six patients received a fluid volume of more than 1,500 ml. In two cases, the preclinical rescue time exceeded 40 min. Three patients presented airway difficulties: one unilateral intubation, one intubation with a GCS 15, and, in one case, the emergency physician failed to intubate. A delay in establishing thoracic drainage occurred in two cases. In four patients, the time from arrival to CT (trauma room time) exceeded 30 min. Delay in hemorrhage control was a major cause of potentially preventable deaths (with a total of six cases). In five cases, the substitution of coagulation medication was insufficient. Therefore, the coagulation status remained abnormal. In two cases, the required coagulation medication and blood products were given with a delay of 33 and 60 min, respectively. In one case, severe pelvic bleeding could not be stopped using non-invasive methods; angiographic embolization or pre-peritoneal packing was not envisaged. In two cases, an iatrogenic injury contributed to potentially preventable deaths. One patient suffered a tension pneumothorax with small shift of the mediastinum rightwards after central venous catheter placement. This was diagnosed with a time delay of 5 h. No thoracic drainage was placed; 12 h later, the patient became hemodynamically unstable and cardiopulmonary resuscitation was necessary. Shortly after that, the patient died. In the second patient, a Shaldon catheter, a two lumens dialysis catheter with a high flow rate, was placed in an artery twice, resulting in major blood loss. In one case, emergency surgery was prolonged to 157 min. Two patients died suffering from MOF and one died suffering from sepsis.
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Preclinical errors
Trauma room A total of 20 patients received more than 1,500 ml fluid volume. Together with the preclinical volume management, 32 patients had more than 1,500 ml infused (Fig. 3). Thoracic drains were established after X-ray in two patients, although clinical symptoms for a pneumothorax were detectable. In one case, re-installation was necessary because of misdirection of the first. The trauma room time (time from admission until CT or surgery) exceeded 30 min in 12 cases. Signs of hemorrhagic shock were found in 33 patients (systolic blood pressure [SBP] B90 mm Hg; hemoglobin [Hb] \10 g dl; pulse rate C100 bpm). Nine of 20 patients with Hb \10 g dl presented no other sign of shock. The following errors were included: no or insufficient administration of coagulation medications in 14 patients, a delay of surgery for hemorrhage control in four patients, and no substitution of red cell concentrates in three patients. In seven patients, an indicated emergency surgery (craniotomy for control of intracranial bleeding, external fixation for fractures of long bones) was performed with a time delay.
World J Surg (2014) 38:3125–3132 Fig. 2 Errors during preclinical rescue
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16 14 12 10 8 6 4 2 0 Airway management errors
Fig. 3 Errors during trauma room treatment
Delay in rescue
Volume management errors
Missed thoracic drain
35 30 25 20 15 10 5 0
The indicated emergency surgery exceeded 120 min in four cases, and, in one case, a second surgery within the first 24 h was necessary. Sepsis was diagnosed in seven cases and MOF in nine cases. A neurosurgical judgment resulted in the decision to apply no further treatment after trauma room therapy and initial diagnostics, resulting in the death of the patient in 19 cases. Whole-body CT was not performed in 42 patients.
Discussion The analysis of errors and deaths, particularly preventable or potentially preventable deaths, is essential for quality improvements in trauma care.
This study investigated elderly trauma patients aged over 75 years. There will be a greater need to focus on this age group in the future due to demographic changes. Results of an urban level 1 trauma center in Germany were demonstrated. To the best of our knowledge, this is the first analysis of this age group. Preventable and potentially preventable deaths The rate of preventable or potentially preventable errors was 9.26 %. In their study about preventable complications and deaths in patients older than 65 years, Pellicane et al. [9] reported a rate of 32 % of preventable complications in all deaths. In this study, patients with an ISS\16 were also included. Kleber et al. [16] reported a rate of 9.8 % potentially preventable and 5.3 % preventable deaths in
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Berlin, Germany. They included all autopsied, direct trauma fatalities, and did not distinguish between ages. In other studies, the rate of preventable or potentially preventable deaths ranges from 21 to 33 % [17–20]. American mature trauma centers presented a rate of 2.5–5.9 % [21–23]. None of the reviewed studies focused on elderly patients. In the decision of the M&M conference and in the authors’ determination of preventable or potentially preventable deaths, the RISC and the Trauma and Injury Severity Score (TRISS) were used, similar to other M&M programs [24]. However, because age is a factor in calculating both scores, they were not used to distinguish between preventable, potentially preventable, and nonpreventable deaths. Patterns of errors Airway management errors were the most frequent preclinical errors. Complications occurred in 13 of 64 intubated patients (20.31 %). In a prospective study from America, incidence of failed intubations was reported as 31 % [25]. Another study found a rate of 15 % failed intubations in a paramedic emergency medical system (EMS) [26]. In a study from Switzerland, the rate of failed intubations performed by junior doctors was 5.7 % [27]. When EMS anesthesiologists performed the intubation, the success rate raised to 99.7 %, and complications were found in 7.9 % [28, 29]. The rate of airway management errors in this study is comparable to that reported when paramedics are responsible for airway management. In Germany, every physician, who undergoes special training, is regarded as qualified to become involved in preclinical emergency treatment. Therefore, it is not only physicians who deal with airway management on a daily basis (such as anesthesiologists) that are involved in preclinical rescue. A delay in preclinical rescue time was found in 11 patients. Even though in many areas a preclinical rescue time of less than 45 min cannot be met, in an urban setting like the one presented in this study, a rescue time of less than 45 min should be manageable in most cases. In the treatment of trauma patients, time is of the essence; therefore, preclinical rescue should be performed as quickly as possible. It is reported that a delay of 3 min for laparotomy because of intra-abdominal bleeding resulted in an increased mortality of 1 % [30]. Volume management was not only a pattern of error in the preclinical setting but also after admission to the hospital. Several studies report a negative effect of excessive fluid replacement [15, 31]. Infusion of more than 1,500 ml led to a higher mortality in elderly patients [32]. More than 50 % of the patients received more than 1,500 ml fluid volume, which was the second most common error in our study.
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Hemorrhage control was the most common error in our study. This appears to be in conjunction with other studies investigating patterns of error in trauma patients [16, 21, 23]. Mostly, this was a human clinical judgment error, because a delay in therapy of abnormal coagulation was found to be most common. Other human errors included delay in performing necessary emergency surgeries/interventions or exceeded time periods in the trauma room or operating room. A prolonged emergency surgery and the time of all performed surgeries within the first 24 h are associated with higher mortality [33]. Therefore, the cut-off to indicate emergency surgery as prolonged was set to 120 min. Huber-Wagner et al. [34] showed a higher survival rate in severely injured patients who underwent a whole-body CT. The most appropriate explanation might be that most of the injuries could be found using a whole-body CT. Therefore, a guideline recommendation is to perform a whole-body CT in severely or suspected severely injured patients [13]. The low rate of performed whole-body CTs (58 %) in the decedents with an ISS C16 might indicate that the severity of trauma tends to be underestimated in elderly patients. Summarizing, our study underlines the need for special training programs for everyone involved in the trauma care of severely injured patients. The outstanding relevance of human errors in preventable or potentially preventable deaths, and in patterns of errors, is reported in the literature [21]. To avoid discussion about preventable or potentially preventable deaths, improvements in primary prevention are also important. In the last decades, great improvements in the active and passive security of motor vehicles have been achieved. Improvements in security for pedestrians and in avoidance of falls from low levels, one of the most common reasons for injury in elderly patients, are also necessary. Limitations This is a retrospective study with all the known limitations endemic to this approach. Data may not be complete, and the motivation for decisions made by the involved staff cannot be determined. No external review of the deaths was performed. This might be the most unbiased way to decide whether or not a death is preventable. In the strictest sense, errors found in the pre-clinical setting could only apply to an EMS similar to that in Germany. Conclusions Preventable or potentially preventable deaths occur in severely injured elderly patients. Incidence is similar to that reported for other age groups.
World J Surg (2014) 38:3125–3132
In the pre-clinical setting, resuscitation airway management errors are the most common. In the clinical setting, the missed control of hemorrhage as a type of human judgment error dominates. Better training in airway management and a more aggressive therapy of hemorrhage might result in a decrease in preventable and potentially preventable deaths. All healthcare staff involved in the treatment of trauma patients should be aware of the significance of these errors in order to be able avoid them where possible.
Conflict of interest authors.
There are no conflicts of interest among the
References ¨ ltere Menschen in Deutsch1. Bevo¨lkerung - Alter im Wandel - A land und der EU - Statistisches Bundesamt (Destatis). https:// www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/ Bevoelkerungsstand/AlterimWandel.html. Accessed 05 May 2014 2. Goodmanson NW, Rosengart MR, Barnato AE, Sperry JL, Peitzman AB, Marshall GT (2012) Defining geriatric trauma: when does age make a difference? Surgery 152(4):668–674 discussion: 674–5 3. Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM (2002) Trauma in the elderly: intensive care unit resource use and outcome. J Trauma 53(3):407–414 4. Newell MA, Rotondo MF, Toschlog EA, Waibel BH, Sagraves SG, Schenarts PJ, Bard MR, Goettler CE (2009) The elderly trauma patient: an investment for the future? J Trauma 67(2):337–340 5. Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, Shaftan GW (1990) Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 30(2):129–134 discussion: 134–6 6. Victorino GP, Chong TJ, Pal JD (2003) Trauma in the elderly patient. Arch Surg 138(10):1093–1098 7. Lehmann R, Beekley A, Casey L, Salim A, Martin M (2009) The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg 197(5):571–574 discussion: 574–5 8. Martin JT, Alkhoury F, O’Connor JA, Kyriakides TC, Bonadies JA (2010) ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg 76(1):65–69 9. Pellicane JV, Byrne K, DeMaria EJ (1992) Preventable complications and death from multiple organ failure among geriatric trauma victims. J Trauma 33(3):440–444 10. MacKenzie EJ (1999) Review of evidence regarding trauma system effectiveness resulting from panel studies. J Trauma 47(3 Suppl):S34–S41 11. Shackford SR, Hollingsworth-Fridlund P, McArdle M, Eastman AB (1987) Assuring quality in a trauma system: the Medical Audit Committee: composition, cost, and results. J Trauma 27(8):866–875 12. Reason JT (2001) Understanding adverse events: the human factor. In: Vincent C (ed) Clinical risk management: enhancing patient safety. BMJ Books, London, pp 6–30
3131 13. German Trauma Society (DGU): S3 – Guideline on Treatment of Patients with Severe and Multiple Injuries. [http://www.awmf. org/fileadmin/user_upload/Leitlinien/012_D_Ges_fuer_Unfall chirurgie/012-019e_S3_Severe_and_Multiple_Injuries_2012-11. pdf]. Accessed: 05 May 2014 14. Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Ferna´ndez-Monde´jar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent J, Rossaint R (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17(2):R76 15. Schoeneberg C, Schilling M, Keitel J, Kauther MD, Burggraf M, Hussmann B, Lendemans S (2014) TraumaNetwork, Trauma Registry of the DGU, Whitebook, S3 Guideline on treatment of polytrauma/severe injuries: an approach for validation by a retrospective analysis of 2304 patients (2002–2011) of a level 1 trauma centre. Zentralbl Chir. doi:10.1055/s-0033-1360225 16. Kleber C, Giesecke MT, Tsokos M, Haas NP, Buschmann CT (2013) Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 37(5):1154–1161. doi:10.1007/ s00268-013-1964-2 17. Anderson ID, Woodford M, de Dombal FT, Irving M (1988) Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed) 296(6632):1305–1308 18. Kreis DJ, Plasencia G, Augenstein D, Davis JH, Echenique M, Vopal J, Byers P, Gomez G (1986) Preventable trauma deaths: Dade County, Florida. J Trauma 26(7):649–654 19. Stocchetti N, Pagliarini G, Gennari M, Baldi G, Banchini E, Campari M, Bacchi M, Zuccoli P (1994) Trauma care in Italy: evidence of in-hospital preventable deaths. J Trauma 36(3):401–405 20. Zafarghandi M, Modaghegh MS, Roudsari BS (2003) Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals. J Trauma 55(3):459–465 21. Teixeira Pedro G R, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, Browder T, Noguchi TT, Demetriades D (2007) Preventable or potentially preventable mortality at a mature trauma center. J Trauma 63(6):1338–1346 discussion 1346–7 22. Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eastman AB, Virgilio RW, Cooper G, Hammill F, Lynch FP (1992) An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma 32(5):660–665 discussion 665–6 23. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV (2006) Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 244(3):371–380 24. Dutton RP, Stansbury LG, Leone S, Kramer E, Hess JR, Scalea TM (2010) Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997–2008. J Trauma 69(3):620–626 25. Cobas MA, De la Pen˜a MA, Manning R, Candiotti K, Varon AJ (2009) Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 109(2):489–493 26. Wang HE, Cook LJ, Chang CH, Yealy DM, Lave JR (2009) Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation 80(1):50–55 27. Albrecht E, Yersin B, Spahn DR, Fishman D, Hugli O (2006) Success rate of airway management by residents in a pre-hospital emergency setting: a retrospective study. Eur J Trauma 32(6):516–522 28. Nakstad AR, Heimdal H, Strand T, Sandberg M (2011) Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service. Am J Emerg Med 29(6):639–644
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3132 29. Rogna˚s L, Hansen TM, Kirkegaard H, Tønnesen E (2013) Prehospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med 21:58 30. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ (2002) Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 52(3):420–425 31. Hussmann B, Lefering R, Waydhas C, Touma A, Kauther MD, Ruchholtz S, Lendemans S (2013) Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury 44(5):611–617
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World J Surg (2014) 38:3125–3132 32. Ley EJ, Clond MA, Srour MK, Barnajian M, Mirocha J, Margulies DR, Salim A (2011) Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma 70(2):398–400 33. Schoeneberg C, Schilling M, Burggraf M, Fochtmann U, Lendemans S (2014) Reduction in mortality in severely injured patients following the introduction of the ‘‘Treatment of patients with severe and multiple injuries’’ guideline of the German society of trauma surgery: a retrospective analysis of a level 1 trauma center (2010–2012). Injury 45(3):635–638 34. Huber-Wagner S, Lefering R, Qvick L, Ko¨rner M, Kay MV, Pfeifer K, Reiser M, Mutschler W, Kanz K (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373(9673):1455–1461
ORIGINAL SCIENTIFIC REPORT
Preventable and Potentially Preventable Deaths in Severely Injured Elderly Patients: A Single-Center Retrospective Data Analysis of a German Trauma Center Carsten Schoeneberg • Marc Schilling Thomas Probst • Sven Lendemans
•
Published online: 29 August 2014 Socie´te´ Internationale de Chirurgie 2014
Abstract Background Due to widespread demographic changes, populations in industrial countries are ageing. A common tool for quality improvement of trauma care is the analysis of deaths in trauma patients. This study focuses on preventable or potentially preventable deaths, and on patterns of errors in severely injured elderly patients, a group that is under-represented in the literature. Methods Data from a level 1 trauma center in Germany were analyzed for this study. A retrospective chart analysis was performed for all deceased patients older than 75 years with an Injury Severity Score greater than 15. Additionally, the data from the Trauma Registry of the German Society for Trauma Surgery were used. According to a Trauma Division Morbidity and Mortality conference, and after a review of all authors, deaths were classified as preventable, potentially preventable, and non-preventable. Results Of the 2,304 patients admitted to the trauma room, 108 met the inclusion criteria. A total of 62 (57.41 %) patients died. Two deaths were declared as preventable deaths (3.23 %) and eight as potentially preventable (12.90 %). The most common preclinical error was associated with airway management. Hemorrhage control was the leading error in the clinical setting. Excessive fluid volume resuscitation was the second most common error detected. Conclusion The rate of preventable or potentially preventable deaths in severely injured elderly patients is similar to that reported for other age groups. Thus, most errors were human judgment errors or human treatment errors; therefore, education and training in the treatment of severely injured patients is extremely important.
C. Schoeneberg (&) M. Schilling S. Lendemans Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany e-mail: [email protected] M. Schilling e-mail: [email protected] S. Lendemans e-mail: [email protected] T. Probst Department of Trauma, Orthopedic, and Hand Surgery, Municial Hospital Neuss, Lukashospital GmbH, Neuss, Germany e-mail: [email protected]
Abbreviations AIS Abbreviated Injury Scale bpm Beats per minute CT Computed tomography DGU German Society for Trauma Surgery EMS Emergency medical system GCS Glasgow Coma Scale Hb Hemoglobin ICU Intensive care unit ISS Injury Severity Score M&M Morbidity and mortality conference MOF Multi-organ failure RISC Revised injury severity classification
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SPSS TRISS
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Statistical Package for the Social Sciences Trauma and Injury Severity Score
Introduction It is widely known that the population of industrial countries is ageing considerably. For example, in 2011, a total of 21 % of the German population was older than 65 years, compared with 15 % in 1990. This is the highest rate in the EU [1]. Age is a commonly known risk factor for mortality after trauma [2]. Elderly patients also require a higher amount of hospital resources after trauma than do younger patients [3, 4]. However, with an Injury Severity Score (ISS) greater than 30, the length of intensive care unit (ICU) stay is shorter due to increased mortality [3]. Elderly patients often present comorbid conditions, concomitant medication such as anticoagulation drugs, and a decreased physiologic reserve. Therefore, the ability to respond to trauma resuscitation and the impact of the injuries itself is decreased compared with younger patients [5]. Because of medication, the response after hemodynamic shock can be different from that in younger populations with the absence of hypotension and tachycardia [6]. Therefore, the injury severity and the response to resuscitation can be underestimated [7, 8]. A literature research found only a single publication investigating preventable deaths in geriatric trauma patients. This study was published in 1992, and all trauma patients aged over 65 years were included. The authors reported that the decedents were older (77.6 ± 1.5 vs. 74.6 ± 0.4 years) and more severely injured (ISS 23.3 ± 2.7 vs. 8.5 ± 0.5) [9]. The research presented in this study investigates preventable and potentially preventable deaths in severely injured elderly patients. Additionally, any corresponding errors were analyzed. To anticipate the demographic changes and to accommodate the results of Pellicane et al. [9], this study focuses on patients older than 75 years with an ISS greater than 15. To the best of our knowledge, this is the first study to investigate these patients.
Materials and methods This study analyzed data from a level 1 trauma center in Germany. The data were collected prospectively for the national trauma registry, called the Trauma Registry of the German Society for Trauma Surgery (DGU). Data from the Trauma Registry of the DGU have received full approval from the Ethics Committee of the University of
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Witten/Herdecke in Cologne, Germany. As the trauma registry of the DGU is an anonymous register, the Institution Review Board waived the need for patient consent. Hospital records of the patients were also retrospectively analyzed. This study also received approval from the Ethics Committee of the University of Duisburg-Essen in Essen, Germany. The following inclusion criteria were applied: primary admission to the hospital; ISS score C16; C76 years of age; admission occurred between July 2002 and December 2011. Preventable and potentially preventable deaths During a monthly Trauma Division Morbidity and Mortality (M&M) conference, all traumatic deaths are reviewed and classified as preventable, potentially preventable, and non-preventable. This classification was analyzed for a second time by every author on its own. When opinions differed, the case was discussed until a final decision was made. All available clinical patient data, including the pre-hospital emergency physician notes, trauma room documentation, surgery reports, imaging, electronic labs, documentation for the Trauma Registry of the DGU, and in-patient chart were reviewed. MacKenzie published three criteria for a potentially preventable death: the injury must be survivable, the delivery of care is suboptimal, and the error in care must be directly or indirectly implicated in the death of the patient [10]. Shackford et al. [11] defined preventability as follows: ‘‘(1) Anatomic injury or combination of injury considered survivable; (2) Physiologic state at time of arrival of first responder critical to judgment of preventability; patient generally stable; if unstable patient becomes stable with treatment; (3) Evaluation and management suspect in any way.’’ Patterns of errors Errors occurring in the treatment were defined by Reason [12] as ‘‘the failure of a planned action to achieve its desired goal.’’ The recommendations of the DGU Guideline on Treatment of Patients with Severe and Multiple Injuries [13] and the European guideline Management of Bleeding and Coagulopathy Following Major Trauma were used to decide whether or not an error occurred. In detail, the recommendations for pre-clinical airway management are as follows: • •
Multiply injured patients with apnea or gasping must be intubated and ventilated. Multiply injured patients should be intubated and ventilated at the preclinical stage with the following indications:
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• • • •
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hypoxia despite oxygen administration severe craniocerebral trauma with a Glasgow Coma Scale (GCS) \9 trauma-associated hemodynamic instability (systolic blood pressure \90 mmHg) severe chest trauma with respiratory failure.
Trauma admissions 2,304
> 75 years 258
Examples from the recommendations of the European guideline Management of Bleeding and Coagulopathy Following Major Trauma [14] are as follows: •
•
‘‘We recommend that tranexamic acid be administered as early as possible to the trauma patient who is bleeding or at risk of significant hemorrhage at a loading dose of 1 g infused over 10 min, followed by an intravenous infusion of 1 g over 8 h’’ ‘‘We recommend the early use of prothrombin complex concentrate (PCC) for the emergency reversal of vitamin K-dependent oral anticoagulants.’’
The average time of all treated patients in our hospital was used to judge errors in time periods. This resulted in an average time for preclinical rescue of 45 min, for trauma room treatment of 30 min, and for the first emergency surgery of 120 min [15]. In the same study, a higher rate of mortality, among other factors, was associated with prolongation of these time periods [15]. Data were analyzed using the Statistical Package for the Social Sciences, version 21 (IBM, Armonk, NY, USA).
Results Within the observation period, 2,304 patients were admitted to the trauma room. Of these, 258 patients were older than 75 years. A total of 108 patients met the inclusion criteria. The mean GCS was 8.06, the mean ISS was 28.45, the mean Abbreviated Injury Scale (AIS) head was 4.01, and the mean age was 82.2 years. A total of 38.3 % were male patients. A total of 62 patients died after trauma, resulting in a mortality rate of 57.41 %. The expected mortality rate, demonstrated by the Revised Injury Severity Classification (RISC), was 54.55 %. After the M&M conference and author review, two deaths were classified as preventable (3.23 % of deaths, 1.85 % of admissions) and eight deaths as potentially preventable (12.90 % of deaths, 7.41 % of admissions) (Fig. 1). Preventable deaths Both preventable deaths exhibited an accumulation of avoidable errors. The general patients’ data are shown in Table 1. Both patients were intubated although the GCS was 15 at the accident scene. Patient 1 was involved in a traffic
Met inclusion criteria 108
Nonpreventable 98 (90.74%)
Deaths
Survivors
62 (57.41%)
46 (42.59%)
Potentially preventable
Preventable 2 (3.23%)
8 (12.90%)
Fig. 1 Trauma deaths 2002–2011
Table 1 General data for patients whose deaths were preventable Age
ISS
RISC
GCS
AIS head
Sex
Patient 1
76
41
50.8
15
0
Male
Patient 2
83
35
53.5
15
0
Female
AIS Abbreviated Injury Scale, GCS Glasgow Coma Scale, ISS Injury Severity Score, RISC Revised Injury Severity Classification
accident. He suffered a fracture of the femur, a stable fracture of cervical vertebras 3 and 6, and an unstable fracture of the thoracic vertebra 8 without spinal cord injury. In total, 2,500 ml of fluid volume was infused preclinic and at admission. Because of concomitant medication with phenprocoumon, the coagulation status of the patient was abnormal. There was no response in treatment over several days. After extubation, the patient suffered from a drop of oxygen saturation, most likely because of respirator-associated pneumonia, and re-intubation was necessary. After 31 days, the patient died after suffering septic shock. The second patient was involved in a vehicle accident, and suffered open fractures of lower limbs, a tension pneumothorax, and a minor injury to the soft tissue of the elbow. Aspiration occurred during pre-clinical intubation. A total of 3,000 ml fluid volume was infused. A thoracic drainage treating the tension pneumothorax was placed after computed tomography (CT) scans approximately 45 min after arrival at the hospital. Because of the open fractures, the patient underwent emergency surgery, which
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Table 2 General data of patients whose deaths were potentially preventable Patient
GCS
ISS
RISC
AIS head
AIS neck
AIS thorax
AIS abdomen
AIS extremities
AIS skin
Age
1
12
16
38.9
4
0
0
0
0
0
83
2
6
29
79.1
0
2
0
3
4
0
87
3
15
41
86.4
0
0
0
5
4
0
78
4
14
33
65.7
0
0
5
0
2
2
76
5
9
19
13.1
0
0
3
0
3
1
92
6
3
57
87.9
5
2
4
0
4
3
84
7
3
24
67.5
4
2
2
0
0
1
90
8
10
20
27.5
4
0
0
0
2
0
83
AIS Abbreviated Injury Scale, GCS Glasgow Coma Scale, ISS Injury Severity Score, RISC Revised Injury Severity Classification
lasted 201 min. Although, coagulation was abnormal, the patient was treated with heparin. After 7 days, the patient died, suffering from multi-organ failure (MOF).
Patterns of errors in the decedents
Potentially preventable deaths
The preclinical rescue time was exceeded in 11 patients, with a range of 33–114 min. In 11 cases, the infused fluid volume was more than 1,500 ml (Fig. 2). A total of 15 errors occurred with regard to airway management in 13 patients: impossibility of securing the airway (one), re-intubation because of malposition (two), unilateral intubation (three), not indicated intubation (three), no intubation, although it was indicated (three), and aspiration (three). In seven cases, an indicated thoracic drain was not established.
The patient characteristics of the potentially preventable deaths are shown in Table 2. Six patients received a fluid volume of more than 1,500 ml. In two cases, the preclinical rescue time exceeded 40 min. Three patients presented airway difficulties: one unilateral intubation, one intubation with a GCS 15, and, in one case, the emergency physician failed to intubate. A delay in establishing thoracic drainage occurred in two cases. In four patients, the time from arrival to CT (trauma room time) exceeded 30 min. Delay in hemorrhage control was a major cause of potentially preventable deaths (with a total of six cases). In five cases, the substitution of coagulation medication was insufficient. Therefore, the coagulation status remained abnormal. In two cases, the required coagulation medication and blood products were given with a delay of 33 and 60 min, respectively. In one case, severe pelvic bleeding could not be stopped using non-invasive methods; angiographic embolization or pre-peritoneal packing was not envisaged. In two cases, an iatrogenic injury contributed to potentially preventable deaths. One patient suffered a tension pneumothorax with small shift of the mediastinum rightwards after central venous catheter placement. This was diagnosed with a time delay of 5 h. No thoracic drainage was placed; 12 h later, the patient became hemodynamically unstable and cardiopulmonary resuscitation was necessary. Shortly after that, the patient died. In the second patient, a Shaldon catheter, a two lumens dialysis catheter with a high flow rate, was placed in an artery twice, resulting in major blood loss. In one case, emergency surgery was prolonged to 157 min. Two patients died suffering from MOF and one died suffering from sepsis.
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Preclinical errors
Trauma room A total of 20 patients received more than 1,500 ml fluid volume. Together with the preclinical volume management, 32 patients had more than 1,500 ml infused (Fig. 3). Thoracic drains were established after X-ray in two patients, although clinical symptoms for a pneumothorax were detectable. In one case, re-installation was necessary because of misdirection of the first. The trauma room time (time from admission until CT or surgery) exceeded 30 min in 12 cases. Signs of hemorrhagic shock were found in 33 patients (systolic blood pressure [SBP] B90 mm Hg; hemoglobin [Hb] \10 g dl; pulse rate C100 bpm). Nine of 20 patients with Hb \10 g dl presented no other sign of shock. The following errors were included: no or insufficient administration of coagulation medications in 14 patients, a delay of surgery for hemorrhage control in four patients, and no substitution of red cell concentrates in three patients. In seven patients, an indicated emergency surgery (craniotomy for control of intracranial bleeding, external fixation for fractures of long bones) was performed with a time delay.
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16 14 12 10 8 6 4 2 0 Airway management errors
Fig. 3 Errors during trauma room treatment
Delay in rescue
Volume management errors
Missed thoracic drain
35 30 25 20 15 10 5 0
The indicated emergency surgery exceeded 120 min in four cases, and, in one case, a second surgery within the first 24 h was necessary. Sepsis was diagnosed in seven cases and MOF in nine cases. A neurosurgical judgment resulted in the decision to apply no further treatment after trauma room therapy and initial diagnostics, resulting in the death of the patient in 19 cases. Whole-body CT was not performed in 42 patients.
Discussion The analysis of errors and deaths, particularly preventable or potentially preventable deaths, is essential for quality improvements in trauma care.
This study investigated elderly trauma patients aged over 75 years. There will be a greater need to focus on this age group in the future due to demographic changes. Results of an urban level 1 trauma center in Germany were demonstrated. To the best of our knowledge, this is the first analysis of this age group. Preventable and potentially preventable deaths The rate of preventable or potentially preventable errors was 9.26 %. In their study about preventable complications and deaths in patients older than 65 years, Pellicane et al. [9] reported a rate of 32 % of preventable complications in all deaths. In this study, patients with an ISS\16 were also included. Kleber et al. [16] reported a rate of 9.8 % potentially preventable and 5.3 % preventable deaths in
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Berlin, Germany. They included all autopsied, direct trauma fatalities, and did not distinguish between ages. In other studies, the rate of preventable or potentially preventable deaths ranges from 21 to 33 % [17–20]. American mature trauma centers presented a rate of 2.5–5.9 % [21–23]. None of the reviewed studies focused on elderly patients. In the decision of the M&M conference and in the authors’ determination of preventable or potentially preventable deaths, the RISC and the Trauma and Injury Severity Score (TRISS) were used, similar to other M&M programs [24]. However, because age is a factor in calculating both scores, they were not used to distinguish between preventable, potentially preventable, and nonpreventable deaths. Patterns of errors Airway management errors were the most frequent preclinical errors. Complications occurred in 13 of 64 intubated patients (20.31 %). In a prospective study from America, incidence of failed intubations was reported as 31 % [25]. Another study found a rate of 15 % failed intubations in a paramedic emergency medical system (EMS) [26]. In a study from Switzerland, the rate of failed intubations performed by junior doctors was 5.7 % [27]. When EMS anesthesiologists performed the intubation, the success rate raised to 99.7 %, and complications were found in 7.9 % [28, 29]. The rate of airway management errors in this study is comparable to that reported when paramedics are responsible for airway management. In Germany, every physician, who undergoes special training, is regarded as qualified to become involved in preclinical emergency treatment. Therefore, it is not only physicians who deal with airway management on a daily basis (such as anesthesiologists) that are involved in preclinical rescue. A delay in preclinical rescue time was found in 11 patients. Even though in many areas a preclinical rescue time of less than 45 min cannot be met, in an urban setting like the one presented in this study, a rescue time of less than 45 min should be manageable in most cases. In the treatment of trauma patients, time is of the essence; therefore, preclinical rescue should be performed as quickly as possible. It is reported that a delay of 3 min for laparotomy because of intra-abdominal bleeding resulted in an increased mortality of 1 % [30]. Volume management was not only a pattern of error in the preclinical setting but also after admission to the hospital. Several studies report a negative effect of excessive fluid replacement [15, 31]. Infusion of more than 1,500 ml led to a higher mortality in elderly patients [32]. More than 50 % of the patients received more than 1,500 ml fluid volume, which was the second most common error in our study.
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Hemorrhage control was the most common error in our study. This appears to be in conjunction with other studies investigating patterns of error in trauma patients [16, 21, 23]. Mostly, this was a human clinical judgment error, because a delay in therapy of abnormal coagulation was found to be most common. Other human errors included delay in performing necessary emergency surgeries/interventions or exceeded time periods in the trauma room or operating room. A prolonged emergency surgery and the time of all performed surgeries within the first 24 h are associated with higher mortality [33]. Therefore, the cut-off to indicate emergency surgery as prolonged was set to 120 min. Huber-Wagner et al. [34] showed a higher survival rate in severely injured patients who underwent a whole-body CT. The most appropriate explanation might be that most of the injuries could be found using a whole-body CT. Therefore, a guideline recommendation is to perform a whole-body CT in severely or suspected severely injured patients [13]. The low rate of performed whole-body CTs (58 %) in the decedents with an ISS C16 might indicate that the severity of trauma tends to be underestimated in elderly patients. Summarizing, our study underlines the need for special training programs for everyone involved in the trauma care of severely injured patients. The outstanding relevance of human errors in preventable or potentially preventable deaths, and in patterns of errors, is reported in the literature [21]. To avoid discussion about preventable or potentially preventable deaths, improvements in primary prevention are also important. In the last decades, great improvements in the active and passive security of motor vehicles have been achieved. Improvements in security for pedestrians and in avoidance of falls from low levels, one of the most common reasons for injury in elderly patients, are also necessary. Limitations This is a retrospective study with all the known limitations endemic to this approach. Data may not be complete, and the motivation for decisions made by the involved staff cannot be determined. No external review of the deaths was performed. This might be the most unbiased way to decide whether or not a death is preventable. In the strictest sense, errors found in the pre-clinical setting could only apply to an EMS similar to that in Germany. Conclusions Preventable or potentially preventable deaths occur in severely injured elderly patients. Incidence is similar to that reported for other age groups.
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In the pre-clinical setting, resuscitation airway management errors are the most common. In the clinical setting, the missed control of hemorrhage as a type of human judgment error dominates. Better training in airway management and a more aggressive therapy of hemorrhage might result in a decrease in preventable and potentially preventable deaths. All healthcare staff involved in the treatment of trauma patients should be aware of the significance of these errors in order to be able avoid them where possible.
Conflict of interest authors.
There are no conflicts of interest among the
References ¨ ltere Menschen in Deutsch1. Bevo¨lkerung - Alter im Wandel - A land und der EU - Statistisches Bundesamt (Destatis). https:// www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/ Bevoelkerungsstand/AlterimWandel.html. Accessed 05 May 2014 2. Goodmanson NW, Rosengart MR, Barnato AE, Sperry JL, Peitzman AB, Marshall GT (2012) Defining geriatric trauma: when does age make a difference? Surgery 152(4):668–674 discussion: 674–5 3. Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM (2002) Trauma in the elderly: intensive care unit resource use and outcome. J Trauma 53(3):407–414 4. Newell MA, Rotondo MF, Toschlog EA, Waibel BH, Sagraves SG, Schenarts PJ, Bard MR, Goettler CE (2009) The elderly trauma patient: an investment for the future? J Trauma 67(2):337–340 5. Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, Shaftan GW (1990) Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 30(2):129–134 discussion: 134–6 6. Victorino GP, Chong TJ, Pal JD (2003) Trauma in the elderly patient. Arch Surg 138(10):1093–1098 7. Lehmann R, Beekley A, Casey L, Salim A, Martin M (2009) The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg 197(5):571–574 discussion: 574–5 8. Martin JT, Alkhoury F, O’Connor JA, Kyriakides TC, Bonadies JA (2010) ‘Normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. Am Surg 76(1):65–69 9. Pellicane JV, Byrne K, DeMaria EJ (1992) Preventable complications and death from multiple organ failure among geriatric trauma victims. J Trauma 33(3):440–444 10. MacKenzie EJ (1999) Review of evidence regarding trauma system effectiveness resulting from panel studies. J Trauma 47(3 Suppl):S34–S41 11. Shackford SR, Hollingsworth-Fridlund P, McArdle M, Eastman AB (1987) Assuring quality in a trauma system: the Medical Audit Committee: composition, cost, and results. J Trauma 27(8):866–875 12. Reason JT (2001) Understanding adverse events: the human factor. In: Vincent C (ed) Clinical risk management: enhancing patient safety. BMJ Books, London, pp 6–30
3131 13. German Trauma Society (DGU): S3 – Guideline on Treatment of Patients with Severe and Multiple Injuries. [http://www.awmf. org/fileadmin/user_upload/Leitlinien/012_D_Ges_fuer_Unfall chirurgie/012-019e_S3_Severe_and_Multiple_Injuries_2012-11. pdf]. Accessed: 05 May 2014 14. Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Ferna´ndez-Monde´jar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent J, Rossaint R (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17(2):R76 15. Schoeneberg C, Schilling M, Keitel J, Kauther MD, Burggraf M, Hussmann B, Lendemans S (2014) TraumaNetwork, Trauma Registry of the DGU, Whitebook, S3 Guideline on treatment of polytrauma/severe injuries: an approach for validation by a retrospective analysis of 2304 patients (2002–2011) of a level 1 trauma centre. Zentralbl Chir. doi:10.1055/s-0033-1360225 16. Kleber C, Giesecke MT, Tsokos M, Haas NP, Buschmann CT (2013) Trauma-related preventable deaths in Berlin 2010: need to change prehospital management strategies and trauma management education. World J Surg 37(5):1154–1161. doi:10.1007/ s00268-013-1964-2 17. Anderson ID, Woodford M, de Dombal FT, Irving M (1988) Retrospective study of 1000 deaths from injury in England and Wales. Br Med J (Clin Res Ed) 296(6632):1305–1308 18. Kreis DJ, Plasencia G, Augenstein D, Davis JH, Echenique M, Vopal J, Byers P, Gomez G (1986) Preventable trauma deaths: Dade County, Florida. J Trauma 26(7):649–654 19. Stocchetti N, Pagliarini G, Gennari M, Baldi G, Banchini E, Campari M, Bacchi M, Zuccoli P (1994) Trauma care in Italy: evidence of in-hospital preventable deaths. J Trauma 36(3):401–405 20. Zafarghandi M, Modaghegh MS, Roudsari BS (2003) Preventable trauma death in Tehran: an estimate of trauma care quality in teaching hospitals. J Trauma 55(3):459–465 21. Teixeira Pedro G R, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, Browder T, Noguchi TT, Demetriades D (2007) Preventable or potentially preventable mortality at a mature trauma center. J Trauma 63(6):1338–1346 discussion 1346–7 22. Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eastman AB, Virgilio RW, Cooper G, Hammill F, Lynch FP (1992) An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma 32(5):660–665 discussion 665–6 23. Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV (2006) Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Ann Surg 244(3):371–380 24. Dutton RP, Stansbury LG, Leone S, Kramer E, Hess JR, Scalea TM (2010) Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997–2008. J Trauma 69(3):620–626 25. Cobas MA, De la Pen˜a MA, Manning R, Candiotti K, Varon AJ (2009) Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 109(2):489–493 26. Wang HE, Cook LJ, Chang CH, Yealy DM, Lave JR (2009) Outcomes after out-of-hospital endotracheal intubation errors. Resuscitation 80(1):50–55 27. Albrecht E, Yersin B, Spahn DR, Fishman D, Hugli O (2006) Success rate of airway management by residents in a pre-hospital emergency setting: a retrospective study. Eur J Trauma 32(6):516–522 28. Nakstad AR, Heimdal H, Strand T, Sandberg M (2011) Incidence of desaturation during prehospital rapid sequence intubation in a physician-based helicopter emergency service. Am J Emerg Med 29(6):639–644
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3132 29. Rogna˚s L, Hansen TM, Kirkegaard H, Tønnesen E (2013) Prehospital advanced airway management by experienced anaesthesiologists: a prospective descriptive study. Scand J Trauma Resusc Emerg Med 21:58 30. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ (2002) Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 52(3):420–425 31. Hussmann B, Lefering R, Waydhas C, Touma A, Kauther MD, Ruchholtz S, Lendemans S (2013) Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury 44(5):611–617
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World J Surg (2014) 38:3125–3132 32. Ley EJ, Clond MA, Srour MK, Barnajian M, Mirocha J, Margulies DR, Salim A (2011) Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma 70(2):398–400 33. Schoeneberg C, Schilling M, Burggraf M, Fochtmann U, Lendemans S (2014) Reduction in mortality in severely injured patients following the introduction of the ‘‘Treatment of patients with severe and multiple injuries’’ guideline of the German society of trauma surgery: a retrospective analysis of a level 1 trauma center (2010–2012). Injury 45(3):635–638 34. Huber-Wagner S, Lefering R, Qvick L, Ko¨rner M, Kay MV, Pfeifer K, Reiser M, Mutschler W, Kanz K (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373(9673):1455–1461
