Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths.

BACKGROUND: A fundamental goal of continuous process improvement programs is to evaluate and improve the ratio of actual to expected mortality. To study this, we examined contributors to error-associated deaths during two consecutive periods from 1996 to 2004 (period 1) and 2005 to 2014 (period 2). METHODS: All deaths at a level I trauma center with an anticipated probability of death less than 50% and/or identified through process improvement committees were examined. Demographics were assessed for trend only because period 1 data were only available in median and interquartile range. Each death was critically appraised to identify potential error, with subsequent classification of error type, phase, cause, and contributing cognitive processes, with comparison of outcomes made using χ test of independence. RESULTS: During period 1, there were a total of 44,401 admissions with 2,594 deaths and 64 deaths (2.5%) associated with an error, compared with 60,881 admissions during period 2 with 2,659 deaths and 77 (2.9%) associated with an error. Deaths associated with an error occurred in younger and less severely injured patients in period 1 and were likely to occur during the early phase of care, primarily from failed resuscitation and hemorrhage control. In period 2, deaths occurred in older more severely injured patients and were likely to occur in the later phase of care primarily because of respiratory failure from aspiration. CONCLUSION: Despite injured patients being older and more severely injured, error-associated deaths during the early phase of care that was associated with hemorrhage improved over time. Successful implementation of system improvements resolved issues in the early phase of care but shifted deaths to later events during the recovery phase including respiratory failure from aspiration. This study demonstrates that ongoing evaluation is essential for continuous process improvement and realignment of efforts, even in a mature trauma system. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.

Duration of Respiratory Failure After Trauma Is Not Associated With Increased Long-Term Mortality.

OBJECTIVES: Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival. DESIGN: Retrospective cohort of trauma patients. SETTING: Single center, level 1 trauma center. PATIENTS: Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality. CONCLUSIONS: Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.

An analysis of omitting biliary tract imaging in 668 subjects admitted to an acute care surgery service with biochemical evidence of choledocholithiasis.

BACKGROUND: No consensus exists for the timing and utility of biliary imaging in patients with preoperative concern for choledocholithiasis. METHODS: Admissions to an acute care surgery service with evidence of choledocholithiasis undergoing same-admission cholecystectomy without preoperative or intraoperative imaging were identified. One-way analysis of variance on the log-transformed outcomes, with the Tukey-Kramer multiple comparison procedure, were used to compare means between groups. RESULTS: A total of 668 patients with elevated but downtrending liver enzymes underwent cholecystectomy without preoperative or intraoperative imaging. Thirty-eight patients (5.7%) had postoperative biliary imaging, of whom 22 (3.3%) had definite choledocholithiasis. One case of postoperative cholangitis occurred which required readmission and endoscopic retrograde cholangiopancreatography with no long-term morbidity. Presenting liver enzymes were significantly higher in the group found to have retained stones postoperatively than those without retained stones. CONCLUSIONS: Patients presenting with biochemical evidence of choledocholithiasis who downtrend preoperatively can be safely managed by cholecystectomy with omission of biliary tract imaging.

Establishing benchmarks for the management of elevated liver enzymes and/or dilated biliary trees in an urban safety net hospital: analysis of 915 subjects.

BACKGROUND: The push for public reporting of outcomes necessitates relevant benchmarks for disease states across different settings. This study establishes benchmarks for choledocholithiasis management in a safety net hospital setting. METHODS: We reviewed all patients admitted to our acute care surgery service with biochemical evidence of choledocholithiasis who underwent same-admission cholecystectomy (CCY) between July 2012 and December 2013. RESULTS: During this 18-month period, 915 patients were admitted with biochemical evidence of choledocholithiasis. Descriptive statistics for the cohort are provided, which include a 51% rate of obesity and 95% rate of pathologic cholecystitis. Conversion rates of 4% and complication rates of 6% were found. The majority had a CCY without biliary imaging (n = 630, 68.9%). CONCLUSIONS: Relevant benchmarks are characterized, and results of a practice pattern of omitting pre- or intraoperative biliary tree imaging are described. These findings serve as a first benchmark of choledocholithiasis management for urban safety net hospitals.

Nasal swabs collected routinely to screen for colonization by methicillin-resistant Staphylococcus aureus in intensive care units are a sensitive screening test for the organism in clinical cultures.

BACKGROUND: Many hospitals screen patients for methicillin-resistant Staphylococcus aureus (MRSA) on admission to the intensive care unit (ICU). We hypothesized that this screening information could be used to assist with empiric antibiotic decisions. METHODS: The medical records of patients admitted to a university-affiliated community hospital as well as a tertiary-care university hospital were reviewed. Patients admitted to the ICU were screened for MRSA colonization with a nasal swab that was analyzed with either chromogenic medium (hospital 1) or polymerase chain reaction (PCR) (hospital 2). The results of the nasal swab were compared with clinical culture results. RESULTS: There were 141 patients, and 167 cultures were obtained. The majority of the cultures (70%) were performed on sputum specimens in an effort to diagnose pneumonia. The remaining cultures were performed on blood (10.1%), incisions (21.5%), and urine (3.4%). The overall sensitivity of nasal swab results was 69.5%. However, the sensitivity was significantly higher for nasal swab screening performed within six days of clinical cultures compared with screening performed seven days or more before cultures were obtained. (79% vs. 46%; p < 0.0001). Sensitivity also differed significantly depending on the surveillance method, being significantly higher among patients screened with PCR within six days of developing an infection than in patients screened with chromogenic medium (88% vs. 65.5%; p = 0.006). CONCLUSION: Screening with PCR analysis of nasal swab specimens is a highly sensitive test for MRSA in clinical cultures. Clinicians may be able to use the swab results to tailor more appropriate empiric antimicrobial regimens. The results with chromogenic medium screening are markedly poorer, which suggests that clinicians should view them with caution.

A novel technique to skin graft abdominal wall wounds surrounding enterocutaneous fistulas.

BACKGROUND: Enterocutaneous fistulas often are associated with large abdominal wall wounds. Successful skin grafting of these sites is difficult, as the bed is constantly bathed by enteric contents. A method to graft these sites successfully would provide an important advance in their treatment. METHODS: The medical records of patients undergoing skin grafting of a site around an enterocutaneous fistula were reviewed. The amount of fistula output at the time of grafting was recorded. The method of grafting, as well as the means of protecting the graft from enteric exposure, were noted. Skin grafts were evaluated for the extent of "take." RESULTS: Seven patients met the inclusion criteria. After 1-2 weeks, the graft take was 90% in three patients, 80% in two patients, and 50% in two patients. After 1 month, there was complete epithelialization in 85% of patients, and the remaining patient had most of the site epithelialized. This healing allowed placement of an ostomy appliance in all patients. The fistula output was >400 mL per day in 70% of the patients. Multiple techniques were used to divert enteric flow away from the graft, but the most common was placement of a negative pressure dressing that concomitantly secured the graft and allowed enteric diversion. CONCLUSION: The presence of a high-output enterocutaneous fistula does not preclude successful skin grafting. Such grafting can accelerate wound healing as well as improve skin and site hygiene by allowing the placement of an ostomy device.

Penetrating pediatric trauma owing to improper child safety seat use.

We present a case of a 15-month-old child with a history of thoracic impalement after improper safety seat restraint. The foreign body was stabilized with bulky dressings in the field before transport. Imaging revealed possible pulmonary artery involvement; and consequently, a thoracotomy was done to obtain vascular control before removal. We use this case to highlight prehospital care and operative management of a patient with foreign body impalement.