Seven hundred fifty-three consecutive deaths in a level I trauma center: the argument for injury prevention.
BACKGROUND
The past century has seen improvement in trauma care, with a resulting decrease in therapeutically preventable deaths. We hypothesize that further major reduction in injury mortality will be obtained through injury prevention, rather than improvements in therapy.


METHODS
Seven hundred fifty-three deaths in an American College of Surgeons-verified, Level I trauma center were reviewed as they occurred. Deaths were classified as therapeutically not preventable, possibly preventable, or preventable. These charts were also reviewed for factors that might have prevented or lessened the severity of the injury.


RESULTS
Mean age was 43, mean Glasgow Coma Scale score was 5, mean Revised Trauma Score was 4, mean Injury Severity Score was 41, and mean probability of survival was 0.25 (according to TRISS). Forty-six percent underwent cardiopulmonary resuscitation in the field, 52% died within 12 hours, 74% died within 48 hours, and 86% died within 7 days. Primary causes of death included central nervous system injury in 51%, irreversible shock in 21%, multiple injuries (shock plus central nervous system injury) in 9%, multiple organ failure/sepsis and other causes in 3%, and pulmonary embolus in 0.1%. Seven hundred one (93%) were classified as not preventable with a change in therapy, 32 (4.2%) were classified as potentially preventable with a change in therapy, and 20 were classified as preventable with a change in therapy (2.6%). Forty-six percent had cardiopulmonary resuscitation performed before or immediately on arrival to the hospital. Another 23% had vital signs present on arrival, but had a Glasgow Coma Scale score of <or= 4. Of the 546 unintentionally injured patients, 58% had an identifiable factor that contributed to the presence and/or severity of the injury (intoxication, restraint and helmet use), with 28% of patients having a positive blood alcohol level. Of the 206 patients with intentional injuries, 44% were intoxicated at the time of their death. Commensurate with driving-while-intoxicated prevention program(s), the percentage of intoxicated patients significantly ( p= 0.03) decreased from 45% to 34% over the same 7-year period.


CONCLUSIONS
Dramatically improving therapy (no errors, cure for multiple organ failure, sepsis, and pulmonary embolus) in a modern trauma system would decrease trauma mortality by 13%. In contrast, more than half of all deaths are potentially preventable with preinjury behavioral changes. Injury prevention is critical to reducing deaths in the modern trauma system.
Stewart
Ronald M
RM
Department of Surgery, University of Texas Health Science Center at San Antonio, University Health System, San Antonio, Texas 78229-3900, USA. stewartr@uthscsa.edu.
Myers
John G
JG
Dent
Daniel L
DL
Ermis
Peter
P
Gray
Gina A
GA
Villarreal
Roberto
R
Blow
Osbert
O
Woods
Brian
B
McFarland
Marilyn
M
Garavaglia
Jan
J
Root
Harlan D
HD
Pruitt
Basil A
BA
D000058:Accidental Falls / Q000706:statistics & numerical data; D000063:Accidents, Traffic / Q000706:statistics & numerical data; D000328:Adult; D000428:Alcohol Drinking / Q000009:adverse effects / Q000453:epidemiology; D002423:Cause of Death; D005544:Forecasting; D015600:Glasgow Coma Scale; D006292:Health Priorities; D006708:Homicide / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D019300:Medical Errors / Q000517:prevention & control; D011322:Primary Prevention; D012189:Retrospective Studies; D012307:Risk Factors; D019966:Substance-Related Disorders / Q000150:complications / Q000453:epidemiology; D013405:Suicide / Q000706:statistics & numerical data; D016019:Survival Analysis; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D017749:Total Quality Management; D014193:Trauma Centers / Q000592:standards / Q000706:statistics & numerical data*; D014194:Traumatology / Q000592:standards; D014947:Wounds and Injuries / Q000145:classification / Q000401:mortality* / Q000517:prevention & control*