Roy Nobhojit, Kizhakke Veetil Deepa, Khajanchi Monty Uttam, Kumar Vineet, Solomon Harris, Kamble Jyoti, Basak Debojit, Tomson Göran, von Schreeb Johan
Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
BMC Health Serv Res. 2017 Feb 16;17(1):142. doi: 10.1186/s12913-017-2085-7.
A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery.
All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI).
During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging.
Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.
对创伤死亡进行系统分析是印度医院提高创伤救治质量的重要一步。本研究评估了印度五家医院可预防的创伤死亡数量，并采用同行评审流程来确定创伤护理提供过程中的改进机会（OFI）。
回顾性提取印度五家城市大学医院住院30天内发生的所有创伤死亡病例的人口统计学信息、损伤机制、转运状态、临床、检查及手术结果描述的损伤情况。采用混合方法，根据标准化损伤严重度评分（ISS）将病例定量分层为轻度（1 - 8分）、中度（9 - 15分）、重度（16 - 25分）、极重度（26 - 75分）ISS类别，并按死亡时间分为24小时内、7天或30天内。采用同行评审和德尔菲法，在印度背景下定义最佳创伤护理，并使用以下类别评估每例死亡的可预防性：可预防（P）、潜在可预防（PP）、不可预防（NP）和不可预防但护理本可改善（NPI）。
在18个月的研究期间，共有11,671例创伤入院患者，30天内死亡2523例（21.6%）。在2057例符合条件的死亡病例中，可预防死亡的总体比例为58%。在ISS评分轻度的患者中，71%的死亡是可预防的。中度类别中，56%是可预防的，重度组中60%、极重度组中44%是可预防的。创伤性脑损伤和烧伤占不可预防死亡的大部分。可预防死亡子集中的重要改进领域包括气道管理不足（14.3%）和控制出血的复苏不足（16.3%）。与系统相关的问题包括缺乏方案、未遵守方案、院前延误和影像检查延误。
所有创伤死亡病例中有58%被归类为可预防。损伤严重度评分低于16分的死亡病例中有三分之二是可预防的。这一庞大的印度城市创伤患者亚组可能通过紧急关注和纠正措施得以挽救。气道管理及液体复苏、控制出血和手术决策方案等低成本干预措施被确定为改进机会。建立临床方案和及时的创伤护理提供流程是改善护理的下一步措施。
