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Trauma-related Preventable Deaths in Berlin 2010: Need to Change Prehospital Management Strategies and Trauma Management Education
Background
Fatal trauma is one of the leading causes of death in Western industrialized countries. The aim of the present study was to determine the preventability of traumatic deaths, analyze the medical measures related to preventable deaths, detect management failures, and reveal specific injury patterns in order to avoid traumatic deaths in Berlin.
Materials and methods
In this prospective observational study all autopsied, direct trauma fatalities in Berlin in 2010 were included with systematic data acquisition, including police files, medical records, death certificates, and autopsy records. An interdisciplinary expert board judged the preventability of traumatic death according to the classification of non-preventable (NP), potentially preventable (PP), and definitively preventable (DP) fatalities.
Results
Of the fatalities recorded, 84.9 % (
n
= 224) were classified as NP, 9.8 % (
n
= 26) as PP, and 5.3 % (
n
= 14) as DP. The incidence of severe traumatic brain injury (sTBI) was significantly lower in PP/DP than in NP, and the incidence of fatal exsanguinations was significantly higher. Most PP and NP deaths occurred in the prehospital setting. Notably, no PP or DP was recorded for fatalities treated by a HEMS crew. Causes of DP deaths consisted of tension pneumothorax, unrecognized trauma, exsanguinations, asphyxia, and occult bleeding with a false negative computed tomography scan.
Conclusions
The trauma mortality in Berlin, compared to worldwide published data, is low. Nevertheless, 15.2 % (
n
= 40) of traumatic deaths were classified as preventable. Compulsory training in trauma management might further reduce trauma-related mortality. The main focus should remain on prevention programs, as the majority of the fatalities occurred as a result of non-survivable injuries.
Journal Article
Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial
Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.
We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973.
Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28).
No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care.
National Institute for Health Research Health Services and Delivery Research Programme.
Journal Article
Comparison of Long-Term Outcomes of Colonic Stent as “Bridge to Surgery” and Emergency Surgery for Malignant Large-Bowel Obstruction: A Meta-Analysis
Background
The short-term safety and efficacy of insertion of a self-expandable metallic colonic stent followed by elective surgery, bridge to surgery (BTS), for malignant large-bowel obstruction (MLBO) have been well described. However, long-term oncological outcomes are still debated. Hence, this study is conducted to evaluate long-term outcomes of colonic stent insertion followed by surgery for MLBO.
Methods
A comprehensive electronic literature search through May 2014 was performed to identify studies comparing long-term outcomes between BTS and emergency surgery for MLBO. The main outcome measures were overall survival (OS), disease-free survival (DFS), and recurrence. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) with 95 % confidence intervals (95 % CIs).
Results
There were 11 studies that matched the criteria for inclusion, yielding a total of 1136 patients, of whom 432 (38.0 %) underwent BTS and 704 (62.0 %) underwent emergency surgery. In OS analyses of all patients and patients who underwent curative resection, BTS was similar to emergency surgery [(RR = 0.95; 95 % CI 0.75–1.21;
P
= 0.66) (RR = 0.96; 95 % CI 0.67–1.37;
P
= 0.82), respectively]. DFS (RR = 1.06; 95 % CI 0.91–1.24;
P
= 0.43) and recurrence (RR = 1.13; 95 % CI 0.82–1.54;
P
= 0.46) did not differ significantly between the BTS and emergency surgery groups.
Conclusions
Results of this meta-analysis on long-term as well as well-described short-term outcomes suggest that BTS could be a promising alternative strategy for MLBO patients.
Journal Article
Outcomes of Medical Emergencies on Commercial Airline Flights
This study describes 11,920 in-flight medical emergencies on the basis of consultations from five major airlines to a physician-directed communications center. In nearly half the emergencies, physicians on board provided assistance, and in 7.3%, the aircraft was diverted.
Commercial airlines serve approximately 2.75 billion passengers worldwide annually. When in-flight medical emergencies occur, access to care is limited. Physicians and other medical professionals are often called on to assist when traveling, despite limited training or experience with these situations.
1
Airlines partner with health care institutions to deliver real-time medical advice from an emergency call center to airline personnel, in an effort to improve the quality of care provided to passengers.
There is limited information on the incidence and characteristics of in-flight medical emergencies.
2
Although previous studies of these events have characterized the incidence, categories of symptoms, rates of aircraft . . .
Journal Article
Resuscitation policy should focus on the patient, not the decision
Zoë Fritz and colleagues discuss new approaches to resuscitation decisions that incorporate broader goals of care
Journal Article
Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis
Background
The use of a colonic stent as a bridge to surgery aims to provide patients with elective one-stage surgical resection while reducing stoma creation and postoperative complications. This study used meta-analytic techniques to compare the outcomes of stent use as a bridge to surgery and emergency surgery in the management of obstructive colorectal cancer.
Methods
A literature search of Medline, Embase, Cochrane controlled trials registry, and the Chinese Biomedical Literature Database was performed on all studies comparing stent as a bridge to surgery and emergency surgery for obstructive colorectal cancer. A meta-analysis of the included studies was carried out to identify the differences in outcomes between the two procedures.
Results
Eight studies matched the criteria for inclusion and reported on the outcomes of 601 patients, of whom 232 (38.6%) underwent stent insertion and 369 (61.4%) underwent emergency surgery. Fewer patients in the stent group needed intensive care (risk ratio [RR], 0.42; 95% confidence interval [CI], 0.19–0.93;
p
= 0.03) and stoma creation (RR, 0.70; 95% CI, 0.50–0.99;
p
= 0.04). The primary anastomosis rate in the stent group was higher (RR, 1.62; 95% CI, 1.21–2.16;
p
= 0.001). Overall complications (RR, 0.42; 95% CI, 0.24–0.71;
p
= 0.001), including anastomotic leakage (RR, 0.31; 95% CI, 0.14–0.69;
p
= 0.004), were reduced by stent insertion. Stent placement before elective surgery did not adversely affect mortality and long-term survival.
Conclusions
The use of a stent as a bridge to surgery for obstructive left-sided colorectal cancer could increase the chance of primary anastomosis and reduce the need for stoma creation and postprocedural complications. Stent insertion before subsequent surgery has no effect on perioperative mortality and long-term survival.
Journal Article
An integrated approach for designing in-time and economically sustainable emergency care networks: A case study in the public sector
Emergency Care Networks (ECNs) were created as a response to the increased demand for emergency services and the ever-increasing waiting times experienced by patients in emergency rooms. In this sense, ECNs are called to provide a rapid diagnosis and early intervention so that poor patient outcomes, patient dissatisfaction, and cost overruns can be avoided. Nevertheless, ECNs, as nodal systems, are often inefficient due to the lack of coordination between emergency departments (EDs) and the presence of non-value added activities within each ED. This situation is even more complex in the public healthcare sector of low-income countries where emergency care is provided under constraint resources and limited innovation. Notwithstanding the tremendous efforts made by healthcare clusters and government agencies to tackle this problem, most of ECNs do not yet provide nimble and efficient care to patients. Additionally, little progress has been evidenced regarding the creation of methodological approaches that assist policymakers in solving this problem. In an attempt to address these shortcomings, this paper presents a three-phase methodology based on Discrete-event simulation, payment collateral models, and lean six sigma to support the design of in-time and economically sustainable ECNs. The proposed approach is validated in a public ECN consisting of 2 hospitals and 8 POCs (Point of Care). The results of this study evidenced that the average waiting time in an ECN can be substantially diminished by optimizing the cooperation flows between EDs.
Journal Article
Surgical Challenges During the COVID-19 Crisis: A Comparative Study of Inguinal Hernia Treatment in Romania
Background and Objectives: The COVID-19 pandemic disrupted healthcare systems worldwide, leading to the postponement of elective surgeries, including inguinal hernia repair (IHR), as healthcare resources prioritized critical care. This study aims to evaluate the impact of the pandemic on the incidence and outcomes of IHR procedures. Materials and Methods: A retrospective review was conducted on 604 patients who underwent IHR over six years, spanning pre-pandemic, pandemic, and post-pandemic periods. Data on patient demographics, type of surgical procedure (elective or emergency), use of mesh, surgical duration, hospitalization period, and postoperative outcomes were analyzed across the three time frames. Results: Patient age remained consistent across the three periods, but a significant increase in female patients was observed during and after the pandemic (p < 0.001). Elective IHR surgeries significantly decreased during the pandemic (p < 0.001), paralleled by an increase in emergency cases (p = 0.004). In the post-pandemic period, elective surgeries rebounded, while emergency interventions declined (21.9% vs. 10.3%). Mesh repair usage increased notably in the post-pandemic phase (p < 0.001). Although surgeries took longer during the pandemic (p < 0.001), both total and postoperative hospital stays were reduced during and after the pandemic (p < 0.001). Minimal postoperative complications were reported throughout, with only one mortality during the pandemic. Conclusions: This study highlights the need for robust healthcare strategies to maintain elective surgical care during global crises, as delays in IHR may elevate risks for complications like hernia incarceration and strangulation.
Journal Article