Postinjury Complications: Retrospective Study of Causative Factors

Abstract

Background Injury care involves the complex interaction of patient, physician, and environment that impacts patient complications, level of harm, and failure to rescue (FTR). FTR represents the likelihood of a hospital to be unable to rescue patients from death after in-hospital complications. Objective This study aimed to hypothesize that error type and number of errors contribute to increased level of harm and FTR. Methods Patient information was abstracted from weekly trauma performance improvement (PI) records (from January 1, 2016, to July 19, 2017), where trauma surgeons determined the level of harm and identified the factors associated with complications. Level of harm was determined by definitions set forth by the Agency for Healthcare Research and Quality. Logistic regression was used to determine the impact of individual factors on FTR and level of harm, controlling for age, gender, Charlson score, injury severity score (ISS), error (in diagnosis, technique, or judgment), delay (in diagnosis or intervention), and need for surgery. Results A total of 2216 trauma patients presented during the study period. Of 2216 patients, 224 (224/2216, 10.10 %) had complications reported at PI meetings; of these, 31 patients (31/224, 13.8 %) had FTR. PI patients were more likely to be older (mean age 51.3 years, SE 1.58, vs 46.5 years, SE 0.51; P=.008) and have higher ISS (median 22 vs 8; P<.001), compared with patients without complications. Physician-attributable errors (odds ratio [OR] 2.82; P=.001), most commonly errors in technique, and nature of injury (OR 1.91; P=.01) were associated with higher levels of harm, whereas delays in diagnosis or intervention were not. Each additional factor involved increased level of harm (OR 2.09; P<.001) and nearly doubled likelihood of FTR (OR 1.95; P=.01). Conclusions Physician-attributable errors in diagnosis, technique, or judgment are more strongly correlated with harm than delays in diagnosis and intervention. Increasing number of errors identified in patient care correlates with an increasing level of harm and FTR.

Cardiovascular parameters on computed tomography are independently associated with in-hospital complications and outcomes in level-1 trauma patients

“…Previous studies in trauma patients that investigated comorbidities as a risk factor for complications frequently used either ASA classification or the Charlson Comorbidity Index (CCI) to score the severity of comorbidities [ 11 , 12 , 14 , 15 ]. A study by Lima et al of elderly hip fracture patients found that the CCI score was not independently associated with in-hospital delirium ( p ≥ 0.862), but heart disease and chronic obstructive pulmonary disease were [ 14 ].…”

“…Regression analyses were performed crude and adjusted for covariates. Age, sex, ASA classification, and ISS were chosen as covariates for each separate radiologic abnormality parameter based on clinical experience and previous literature [ 10 – 15 ]. Furthermore, age is a risk factor for the radiologic parameters [ 16 – 18 , 28 ].…”

“…Previous studies in trauma patients have shown risk factors for developing complications, including age, sex, injury severity, and pre-existing cardiopulmonary comorbidities [ 10 – 15 ]. Most of these studies were based on medical history data to assess comorbidities.…”

Failure To Rescue, What Can Be Done To Prevent It?

“…Regarding patient factors that can affect FTR, age has been shown in several studies and in several healthcare settings to be associated with FTR, particularly in trauma populations [1,8,14,31,32,50,51]. Besides being associated independently with FTR, increasing age also relates with the risk of developing a cluster of complications, which also increases the risk of FTR [31].…”

“…The comorbidities are also an important factor, since they contribute to the occurrence of complications41; 51, but also to FTR [3,14,31,32,41,50,51]. In trauma patients, the comorbidities associated with FTR are not consensual between studies, in a study the comorbidities associated with FTR were cardiac disease and bleeding disorders, whereas in another study, several comorbidities were associated with the development of complications, but only renal disease, liver disease and coagulopathy were associated with FTR, and reported that in other studies diabetes was also a risk factor for FTR [31,32].…”