American vs. European Trauma Centers: A Comparison of Preventable Deaths. / Comparación de la mortalidad evitable de un trauma center americano vs. un centro de referencia europeo.

INTRODUCTION: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths. METHODS: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy. RESULTS: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001). CONCLUSIONS: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center.

Source of bleeding in trauma patients with pelvic fracture and haemodynamic instability.

INTRODUCTION: The main cause of mortality in trauma patients with pelvic fractures is hypovolemic shock. We analyzed the association between the source of bleeding, mechanism of action and type of fracture. METHODS: Prospective descriptive study involving trauma patients older than 16 years old, admitted to the intensive care unit or dead before admission, with pelvic fractures and hemodynamic instability. Hemodynamic instability was defined as SBP <90 and/or HR> 100 beats/min. Pelvic fracture was defined by the Tile classification. RESULTS: A total of 157 of 1088 trauma patients had pelvic fracture. We included 63 patients, all hemodynamically unstable. A total of 85% of pelvic fractures after falls from great heights bled from the fracture itself, compared to only 44% of victims of impact (hit). A total of 65% of patients with stable pelvic fracture bled from associated lesions; 70% of patients with unstable fracture bled from the fracture itself. There is an interaction between the mechanism of action and type of fracture. The probability of pelvic bleeding is higher in the precipitated patient (> 80%) regardless of the type of fracture. Bleeding from associated injuries is greater in impact victims, doubling when the fracture is stable (91%). CONCLUSIONS: Mechanism of action is a key to determine the source of bleeding in patients with pelvic fracture. After falls patients bleed from the fracture itself, while patients with an impact (hit) can bleed both from the fracture and associated injuries, depending on the type of fracture.

Impact of ATLS training on preventable and potentially preventable deaths.

BACKGROUND: Multiple trauma continues to have a high incidence worldwide. Trauma is the leading cause of death among people between the ages of 10 and 40. The Advanced Trauma Life Support (ATLS) is the most widely accepted method for the initial control and treatment of multiple trauma patients. It is based on the following hypothesis: The application of the ATLS program may reduce preventable or potentially preventable deaths in trauma patients. MATERIALS AND METHODS: The present article reports a retrospective study based on the records of prospectively evaluated trauma patients between January 2007 and December 2012. Trauma patients over the age of 18 admitted to the critical care unit or patients who died before hospital admission were included. A multidisciplinary committee looked for errors in the management of each patient and classified deaths into preventable, potentially preventable, or nonpreventable. We recorded the number of specialists at our center who had received training in the ATLS program. RESULTS: A total of 898 trauma patients were registered. The mean injury severity score was 21 (SD 15), and the mortality rate was 10.7 % (96 cases). There were 14 cases (14.6 %) of preventable or potentially preventable death. The main errors were delay in initiating suitable treatment and performing a computed tomography scan in cases of hemodynamic instability, followed by initiation of incorrect treatment or omission of an essential procedure. As the number of ATLS-trained professionals increases, the rates of potentially preventable or preventable death fall. CONCLUSIONS: Well-founded protocols such as the ATLS can help provide the preparation health professionals need. In our hospital environment, ATLS training has helped to reduce preventable or potentially preventable mortality among trauma patients.

[Spleen injuries in Spain: at what point are we?]. / Traumatismo esplénico en España: ¿en qué punto estamos?

INTRODUCTION: Management of spleen trauma has changed over last decades, although there is no data on its treatment in Spain. The aim of this study is to determine the characteristics of spleen injuries in adults with severe abdominal injuries and how we manage them. METHODS: A prospective study using the databases of six Spanish hospitals: Gregorio Marañón Hospital, Virgen de la Vega Hospital, Torrevieja Hospital, Getafe Hospital, Doce de Octubre Hospital and Corporació Sanitària Parc Taulí. RESULTS: A total of 566 patients who had sustained spleen injuries were analyzed (448 males and 118 females), most of them were due to blunt trauma (94%), and the most frequent mechanism of injury was motor vehicle accident. The mean Injury Severity Score (ISS) was 25.2. The initial treatment was surgical in 56.6% of the patients (85.3% total splenectomy and 14.7% other conservative surgical procedures, of which 4.6% finally failed and required total splenectomy). The remaining 43.4% were initially managed conservatively, but 6.5% of them finally required surgical splenectomy, and in 8.8% angio-embolization was performed. CONCLUSION: In Spain, management of spleen trauma is mainly surgical (particularly splenectomy). Angio-embolization and conservative surgical procedures are now hardly used.

Design and implementation of a "crisis resource management" training program for the initial assessment of polytrauma patients.

INTRODUCTION: To describe the design and implementation of a Crisis Resource Management (CRM) training program for the initial assessment of polytrauma patients. METHODS: Prospectively implemented CRM training program in acute-care tertiary hospital by hospital personnel involved in the care of polytraumatisms. The program has a blended format and 23-h duration, including 11 h of online theoretical training followed by 12-h simulation modules and practical cases devoted to the roles of members of the trauma team, functioning of the polytrauma room, and key aspects of teamwork. The Human Factors Attitude Survey (HFAS) was used to assess attitudes related to non-technical skills, and the End-of-Course Critique (ECC) survey to evaluate satisfaction with training. We evaluated changes in the pre- and post-training assessments. RESULTS: Eighty staff personnel (26% specialists, 16% residents, 29% nurses, 14% nursing assistant, 15% stretcher bearer) participated in three editions of the program. Theoretical knowledge improved from a mean (SD) of 5.95 (1.7) to 8.27 (2.1) (P < .0001). In the HFAS, statistically significant differences in 18 of 23 attitudinal markers were observed, with improvements in all items of "leadership" and "roles", in 4 of 5 items of "situational awareness", and in 4 of 8 items of "communication". Mean values obtained in the ECC questionnaire were also very high. CONCLUSIONS: A CRM training model developed for the initial care of polytrauma patients improved theoretical knowledge and participants perceptions and attitudes regarding leadership, communication, roles, and situational awareness of members of the trauma team.

[Adverse events in general surgery. A prospective analysis of 13,950 consecutive patients]. / Efectos adversos en cirugía general. Análisis prospectivo de 13.950 pacientes consecutivos.

INTRODUCTION: Adverse event (AE) rates in General Surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our Department. We present the results of this work after a 6 year follow-up. MATERIAL AND METHOD: The AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data was entered into data base for rapid access and consultation. The results were routinely presented in Departmental morbidity-mortality sessions. RESULTS: A total of 13,950 patients had suffered 11,254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. CONCLUSIONS: The exhaustive and prospective recording of AE leads to changes in patient safety culture in a Surgery Department and helps decrease the incidence of health care errors.

Correction to: Esogastro-Pleuro-Bronchial Fistula: An Unusual Complication After Sleeve Gastrectomy.

Due to a Production error Figs. 1 and 2 were omitted from the original article.

An evaluation of morbidity and mortality in oncologic gastric surgery with the application of POSSUM, P-POSSUM, and O-POSSUM.

OBJECTIVE: Evaluation of surgical results observed in oncologic gastric surgery with reference to estimation of risks through POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity), P-POSSUM (Portsmouth POSSUM), and O-POSSUM (regression model based on the POSSUM and P-POSSUM, especially designed for gastric and esophagus surgery). METHODS: A prospective follow-up of a cohort of 106 consecutive patients, gastrectomized because of gastric cancer. The variables studied were: age, sex, technical surgery, American Society of Anesthesiologists (ASA) score, the Charlson comorbidity index, morbidity, and mortality. RESULTS: From January 2004 to April 2008, 131 patients were operated on for gastric neoplasia. Of these, 28 patients were excluded: 5 because of nonstandard gastrectomy, 17 because of staging laparoscopy or unresectable cancer after laparotomy, and 3 because of palliative gastroenteroanastomosis; 106 patients were included. We performed 38 total gastrectomies, 65 distal gastrectomies, 2 esophagogastrectomies, and 1 proximal gastrectomy. The mean age was 68 years (standard deviation (SD) = 12.1; range, 34-85 years). Associated comorbidity (Charlson) was 5.4 (SD = 2.7; range, 2-16); ASA 1 at 1.9%; ASA 2 at 36.8%; ASA 3 at 43.4%; and ASA 4 at 17.9%. Expected morbidity, according to POSSUM was 46.7%; observed morbidity was 50.5%. Morbidity ratio observed/expected was 1.08. Expected mortality, according to POSSUM = 13%, according to P-POSSUM = 4.9%, and according to O-POSSUM = 12.1%. Observed mortality was 7.8%. Mortality ratio observed/expected according to POSSUM, P-POSSUM, O-POSSUM was 0.6, 1.6, and 0.6, respectively. Morbidity results were within the confidence interval of the POSSUM estimation. Our results show lower mortality than the POSSUM and the O-POSSUM estimation (P < 0.001) and higher mortality regarding P-POSSUM estimation (P < 0.001). CONCLUSIONS: The control systems of risk allow us continuous evaluation of our results and objective comparison to other teams. Compared with the POSSUM scoring systems, our series showed quality improvement (morbidity and mortality) over time.

Analysis of quality of life after major trauma: a spanish follow-up cohort study.

PURPOSE: Study objectives are to determine whether quality of life is recovered completely after major injury and to identify determinants associated with a worse quality of life. METHODS: Prospective 12-month follow-up of injured patients admitted to the intensive care unit in a Spanish level 1 trauma centre. The main outcome (quality of life) was measured using the EQ-5D-5L. The relationships between sociodemographic factors, injury severity and location, and quality of life scores were evaluated. Mean comparison analysis (95% confidence interval) was performed with the student "t" test for quantitative variables and with chi-squared for proportion comparison (qualitative variables). A multivariate logistic regression (odds ratio and 95% confidence interval) was performed to identify determinants of each dimension, and a multivariate linear regression (regression coefficient and 95% confidence interval) to identify the determinants of EQus and EQvas. RESULTS: Over a 2-year period, 304 patients who met the inclusion criteria were identified, and 200 patients (65.8%) were finally included. Most of patients suffered blunt trauma (91.5%), 72.5% were men, mean age was 47.8, mean ISS was 15.2. The overall health index (EQvas) improved slightly, but its mean value at 12 months was below the Spanish population norm (P < 0.001). In the multivariate analysis, age ≥ 55, female gender and unskilled employment were risk factors for a lower EQvas. Also in the multivariate analysis, having a severe extremity injury was associated with a lower score on the mobility dimension (OR 6.56 95% CI 2.00, 21.55) while age ≥ 55 years was associated with a lower score on the usual activities dimension (OR 3.52 95% CI 1.17, 10.57). Female gender was the most important factor associated with suffering pain (OR 4.54, 95% CI 2.01, 10.27) and depression/anxiety (OR 4.04, 95% CI 1.88, 8.65). In the univariate and multivariate analyses, female gender, age ≥ 55 years, ISS ≥ 25 and severe extremity injury were associated with a lower EQ utility score (EQus). CONCLUSIONS: The quality of life score improves during the first year after major trauma. However, it does not return to the reference levels for the normal population. Female gender and age ≥ 55 years are statistically significant determinants of poorer EQvas and EQus.

Preventable deaths and potentially preventable deaths. What are our errors?

BACKGROUND: A variety of systems have been applied to identify and address errors in the management of multiple trauma patients. This lack of standardisation represents a serious problem. OBJECTIVES: Detect preventable and potentially preventable deaths, and classify all the errors with universal language. METHODS: We studied all trauma patients over 16 admitted to the critical care unit or who died before. In multidisciplinary sessions we decided which deaths were preventable, potentially preventable and non preventable. Guided by ATLS protocols, we detected errors in their management that were classified using the taxonomy of Joint Commission. RESULTS: We registered 1236 trauma patients (ISS 20.77). Of the 115 trauma deaths, 19 were preventable or potentially preventable deaths. We recorded 130 errors in all deaths, 46 of them in preventable or potentially preventable deaths. Using our own classification, the main errors were delay in starting correct treatment or performance of CT in hemodynamically unstable patients. Using the taxonomy of Joint Commission, the main type error was clinical, during the intervention: the delay in initiating correct treatment. Mistakes were made in the emergency department by medical specialists. The incidence of therapeutic and diagnostic errors was similar. The main cause of error was human failure, specifically 'rule-based' errors CONCLUSIONS: Measuring and recording the results is the first step on the way to improving the quality of care for trauma patients. A common language like the taxonomy of Joint Commission will help standardise patient safety data, thus improving the recording of incidents and their analysis and treatment.

[Study on the improvement of trauma patient care: TRAUMACAT project]. / Estudio para la mejoría de la atención hospitalaria inicial del paciente politraumatizado: proyecto TRAUMACAT.

UNLABELLED: Multiple injuries are a major source of morbidity and mortality in young people. The aim of this study was to evaluate the effect of a collaborative strategy to improve the implementation of six clinical indicators, recognized internationally, for the treatment of trauma patient. Prospective, multicentre, pre-and post-intervention study, in ten referral hospitals, offering polytrauma care in Catalonia. 378 patients were recruited for the pre-intervention study and 501 for the post-intervention study. All patients had a history of high-energy trauma requiring admission to critical or semi-critical care unit. INTERVENTION: collaborative strategy aimed at participating professionals, involving the creation of a panel of experts, appointment of monitors to encourage improvements at each centre, training, distribution of information, material and meetings, to exchange impressions. MAIN OUTCOME MEASURES: frequency and characteristics of trauma and percentage of compliance with clinical indicators. Study of 879 trauma patients. The injury mechanism was overall blunt trauma, in both pre and post intervention phases. The medium ISS (injury severity score) was 21 ± 12,8 and the medium TRISS (trauma and injury severity score) was 26,4 ± 11,4. We didn't find differences between both study phases, in relation to the severity of injury. The mortality rate was 11.5%. We observed significant improvement in the performance of chest X-rays (45% vs. 62%) and pelvis X-rays (27% vs. 62%) in the trauma box and in the fixation of the pelvis in patients with a fracture at this site (24% vs. 49%). The use of diagnostic radiology in hemodynamically unstable patients remained low (33%). The collaborative strategy was effective in improving certain indicators of clinical management.

Learning curve for d2 lymphadenectomy in gastric cancer.

Background. D2 lymphadenectomy is a demanding technique which is associated with high morbidity in the West. We report our experience with D2 lymphadenectomy after a training period in Japan. Methods. Prospective, descriptive study in 133 consecutive patients undergoing radical gastrectomy for gastric adenocarcinoma from 2005 to 2011. We analysed the number of lymph nodes removed, observed morbidity/mortality compared with the predictions of POSSUM and O-POSSUM, survival, and disease-free interval for patients with D1 and D2 lymphadenectomy. Results. The morbidity rate in patients with D1 lymphadenectomy was 59.4%. For D2 it was 47.7%. The mortality rate in patients with D1 was 6.7%. In the D2 group it was 6.8%. Median survival was 42.9 months in D1 and 55 months in D2. The disease-free interval was 49 months for D1 and 58 months for D2. Conclusion. The learning curve for D2 lymphadenectomy presents acceptable rates of morbidity and mortality, providing that the technique is learnt at a center with extensive experience.

Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.

BACKGROUND: This study was designed to determine the incidence of adverse events and errors in the care of surgical patients and to demonstrate that continuous prospective collection of data on adverse events can improve quality of care and reduce the number of errors. Retrospective studies find adverse events in approximately 5% of patients admitted. Prospective studies publish figures of approximately 30%. No studies to date have tried to use continuous collection of data on adverse events to reduce the incidence of errors. METHODS: Longitudinal prospective surveillance of adverse events in patients admitted to the Surgery Service during a 22-month period. Sequelae after discharge and errors during hospital stay were evaluated by peer review. RESULTS: A total of 3,807 patients were controlled: 1,177 patients presented 2,193 adverse events (30.9% of admissions); 330 adverse events due to errors were detected in 258 patients (6.9% of admissions). Thirty-four deaths were considered due to adverse events (0.89% of admissions), and in 11 cases mortality was deemed avoidable (0.29% of admissions). The incidence of adverse events remained constant during the study period, but errors decreased from 11.1% to 4.5% (P = 0.005). CONCLUSIONS: This is the first attempt to determine the prevalence of errors in surgery. Introducing systematic programs for recording adverse events can reduce error rates and promote a culture of patient safety in a General Surgery Department.

[A prospective study on the incidence of missed injuries in trauma patients]. / Estudio prospectivo de la incidencia de las lesiones inadvertidas en el paciente politraumatizado.

INTRODUCTION: Missed injuries in trauma patients are injuries not identified during a primary and secondary trauma survey (Advanced Trauma Life Support, ATLS). These injuries are important because of the delay in correct treatment. There is a particularly important sub-group consisting of clinically significant missed injuries, which may cause serious complications in the patient or even death. MATERIAL AND METHOD: A prospective study on missed injuries and clinically significant missed injuries. The study includes all trauma patients older than 16 years admitted to the resuscitation area or who had died during the first 24 hours. We collected injuries, time of their diagnosis and their treatment for each patient. For injuries detected later than 24 hours (i.e. missed injuries) we specified whether it was a clinically significant missed injury and its possible cause. RESULTS: From March of 2006 to January of 2007, 122 trauma patients were recorded with a mean Injury Severity Store of 20 +/- 15.8. Of those, 40.3% had some missed injury, fractures being the most frequent miss (42.7%), followed by chest and abdominal injuries. A clinically significant injury (38.7% of all missed injuries) were found in 17% of trauma patients, the most frequent being spine, abdominal and chest injuries. There is a statistically significant relationship between the presence of missed injuries, high ISS and intubation before or after admission to hospital. CONCLUSIONS: The rate of missed injuries and clinically significant missed injuries is high. Severe trauma patients and intubated patients have higher rates of missed injuries.