Midwest Surgical Association
Continued rationale of why hospital mortality is not an appropriate measure of trauma outcomes

Presented at the 54th Annual Meeting of the Midwest Surgical Association in Galena, IL, August 9, 2011.
https://doi.org/10.1016/j.amjsurg.2011.10.004Get rights and content

Abstract

Background

We hypothesized that standardized withdrawal of care (WOC) practices and an aggressive long-term acute care facility (LTAC) discharge protocol could change hospital mortality and national ranking among trauma centers.

Study Design

Patients who died while admitted to the trauma service at a level 1 trauma center were classified as either an “LTAC candidate” or “not a LTAC candidate” at 4 time points before death.

Results

A total of 216 patients died, and 48% had WOC. Hospital mortality was 3.3%. More than 26% of these qualified as LTAC candidates. The aggressive LTAC discharge protocol reduced hospital mortality by .9%. This was sufficient to move a trauma center into a lower quartile on the National Trauma DataBank benchmark report for 2009.

Conlusions

It is possible to reduce hospital mortality and improve quality ranking with standardized WOC and LTAC discharge protocols. This highlights the importance of measuring outcomes beyond discharge.

Section snippets

Methods

This study is a retrospective chart review of all adult patients consecutively admitted to the trauma service at a regional level 1 trauma center over a 3-year period from January 2007 to December 2009. All patients who died during their admission to the trauma service were identified, and data were collected including patient age, sex, race, insurance status, injury severity score, ICU length of stay, whether or not death occurred after WOC, the primary attending on service in the trauma ICU

Patient characteristics

A total of 6,494 adult patients were admitted to the trauma service of our level 1 regional trauma center over the 3-year study period. The mortality rate over this time period was 3.3%. Of the 216 patients who died during their hospital stay, the mean age and Injury Severity Score (ISS) were 55 and 30, respectively. Patient characteristics and demographics are shown in Table 1.

Evaluation of withdrawal practices

Care was withdrawn before 104 of the 216 (48%) deaths in this study. Despite a high incidence of WOC overall, we found

Comments

In this study, 48% of the study population died after WOC. Previous studies have shown WOC rates in the trauma population range from 40% to 80%.6, 7, 8 This range highlights the lack of standardized withdrawal practices between institutions. Within our own trauma ICU, there was a perceived difference in how often individual trauma intensivists participated in the discussion, decision, and act of withdrawing care from our critically ill trauma patients. We show here that this perceived

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