title: Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths.
abstract: 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.
authors.affiliation: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. nobhojit.roy@ki.se.|Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India. nobhojit.roy@ki.se.|School of Habitat, Tata Institute of Social Sciences, Mumbai, India. nobhojit.roy@ki.se.
authors.forename: Nobhojit
authors.identifier: 0000-0003-2022-7416
authors.initials: N
authors.lastname: Roy
authors.affiliation: School of Habitat, Tata Institute of Social Sciences, Mumbai, India.
authors.forename: Deepa
authors.initials: D
authors.lastname: Kizhakke Veetil
authors.affiliation: Department of Surgery, King Edward Memorial Hospital, Mumbai, India.
authors.forename: Monty Uttam
authors.initials: MU
authors.lastname: Khajanchi
authors.affiliation: Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.
authors.forename: Vineet
authors.initials: V
authors.lastname: Kumar
authors.affiliation: Department of Cultural Anthropology and Global Health, Global Health Institute, Duke University, 205 Friedl Building, Box 90091, Durham, 27708, NC, USA.
authors.forename: Harris
authors.initials: H
authors.lastname: Solomon
authors.affiliation: School of Habitat, Tata Institute of Social Sciences, Mumbai, India.
authors.forename: Jyoti
authors.initials: J
authors.lastname: Kamble
authors.affiliation: School of Habitat, Tata Institute of Social Sciences, Mumbai, India.
authors.forename: Debojit
authors.initials: D
authors.lastname: Basak
authors.affiliation: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Department of Learning, Informatics, Management and Ethics (LIME) and Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Göran
authors.initials: G
authors.lastname: Tomson
authors.affiliation: Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: von Schreeb
mesh_terms: D000293:Adolescent; D000328:Adult; D003645:Death, Sudden / Q000517:prevention & control*; D004812:Epidemiologic Methods; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000517:prevention & control; D006760:Hospitalization / Q000706:statistics & numerical data; D006785:Hospitals, University / Q000706:statistics & numerical data; D006801:Humans; D007194:India / Q000453:epidemiology; D008875:Middle Aged; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data; D014504:Urban Health / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000401:mortality / Q000517:prevention & control*