An analysis of in-hospital deaths at a modern combat support hospital.
BACKGROUND
Analysis of the epidemiology and attribution of in-hospital deaths is a critical component of learning and process improvement for any trauma center. We sought to perform a detailed analysis of in-hospital deaths at a combat support hospital.


METHODS
All patients with trauma who survived to admission and subsequently died before transfer or discharge during a 1-year period were included. The timing, location, pathogenesis, and circumstances surrounding the death were recorded. Opportunities for improvement (OI) of care were identified for analysis. Cases were presented to a panel of experts, and preventability of the deaths was scored on a continuous 10-point scale.


RESULTS
There were 151 deaths, with the predominant mechanisms of gunshot wounds (GSW) (47%) and blast injuries (42%). Most had severe injuries, with a mean Injury Severity Score of 38, pH of 7.09, and base deficit of 12. Predominant causes of death were head injury (45%) and hemorrhage (32%), and 78% died within 1 hour of admission. Most deaths occurred during the intensive care (35%) or resuscitation phases (31%), but the majority of deaths among nonexpectant patients occurred during the operative phase (38%). OI were identified in 74 deaths (49%), and were found in 78% of nonexpectant deaths. Most improvement opportunities occurred during the resuscitation and transport phases. Most potential improvements were identified at the system level (54%) or individual provider level (42%). Preventability scoring showed excellent inter-rater reliability (r = 0.92, p < 0.001). Deaths with high preventability scores (mean >54) were primarily related to delays in hemorrhage control during the transportation (47%) or resuscitation (43%) phases, and attributed to the system (63%) and individual provider levels (70%).


CONCLUSIONS
In-hospital combat trauma-related deaths at a modern Combat support hospital differ significantly from their civilian counterparts, and present multiple OI of care and potential salvage. Delays in prehospital and in-hospital hemorrhage control are the primary contributors to potential preventability.
Department of Surgery, Madigan Army Medical Center, Tacoma, Washington 98431, USA. matthew.martin1@amedd.army.mil
Matthew
M
Martin
John
J
Oh
Heather
H
Currier
Nigel
N
Tai
Alec
A
Beekley
Matthew
M
Eckert
John
J
Holcomb
D000293:Adolescent; D000328:Adult; D001753:Blast Injuries / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006772:Hospitals, Military / Q000706:statistics & numerical data*; D006801:Humans; D015601:Injury Severity Score; D007493:Iraq / Q000453:epidemiology; D054542:Iraq War, 2003-2011; D008297:Male; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States; D055815:Young Adult