PubMed Health⌕ Search

Biomedical subjects

A B Eastman

Publications and source records attributed to A B Eastman.

17 recordsLinked to original sources
PubMed2000

An objective analysis of process errors in trauma resuscitations.

OBJECTIVE: A computer-based system to apply trauma resuscitation protocols to patients with penetrating thoracoabdominal trauma was previously validated for 97 consecutive patients at a Level 1 trauma center by a panel of the trauma attendings and further refined by a panel of national trauma experts. The purpose of this article is to describe how this system is now used to objectively critique the actual care given to those patients for process errors in reasoning, independent of outcome. METHODS: A chronological narrative of the care of each patient was presented to the computer program. The actual care was compared with the validated computer protocols at each decision point and differences were classified by a predetermined scoring system from 0 to 100, based on the potential impact on outcome, as critical/noncritical/no errors of commission, omission, or procedure selection. RESULTS: Errors in reasoning occurred in 100% of the 97 cases studied, averaging 11.9/case. Errors of omission were more prevalent than errors of commission (2. 4 errors/case vs 1.2) and were of greater severity (19.4/error vs 5. 1). The largest number of errors involved the failure to record, and perhaps observe, beside information relevant to the reasoning process, an average of 7.4 missing items/patient. Only 2 of the 10 adverse outcomes were judged to be potentially related to errors of reasoning. CONCLUSIONS: Process errors in reasoning were ubiquitous, occurring in every case, although they were infrequently judged to be potentially related to an adverse outcome. Errors of omission were assessed to be more severe. The most common error was failure to consider, or document, available relevant information in the selection of appropriate care.

Abdominal Injuries↗
PubMed1997

Comparison of the Injury Severity Score and ICD-9 diagnosis codes as predictors of outcome in injury: analysis of 44,032 patients.

INTRODUCTION: Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients. METHODS: Data for the test population were obtained from the SDTR, which contains data from 1985 through 1993 from five participating hospitals. Four data sources were utilized to estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR. These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the Agency for Health Care Policy Research's Health Care Utilization Project Database. Each of these data sources was separately utilized to develop a survival risk ratio (SRR) for each ICD-9 diagnoses code. The SRR was calculated by dividing the number of survivors for patients with each ICD-9 code by the total number of all patients with the particular ICD-9 diagnoses code. The four groups of SRRs derived from our four data sources were used as predictors of survival and the ability of the SRRs to predict survival was compared with the predictive power of the ISS using measures of accuracy, sensitivity, specificity, and receiver operator characteristic curves. RESULTS: During the years 1985 through 1993, complete data were available for analysis on 44,032 patients. Of these, 2,848 patients died during their hospitalization (6%). Survival risk ratios were calculated for each of the diagnoses in the data base. Logistic regression, using the SAS System for statistical analysis, was used to assess the relative predictive power of the ISS and the survival risk ratios derived from the ICD-9 diagnoses codes from each of the four data bases. The analyses demonstrated that the regression models using the SRRs were generally as good or better than ISS as predictors of survival. The predictive power of the SRRs derived from the SDTR data, the North Carolina Trauma Registry data and the Health Care Utilization Report data were the best. In a subsequent analysis, the SRR values and the ISS were added to the patient's age and the revised Trauma Scores to create new predictive models in the mode of TRISS methodology. The analyses again indicated that the models using SRRs had as good or better predictive power than the model using the ISS. CONCLUSIONS: The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.

Abbreviated Injury Scale↗
PubMed1995

A risk analysis of stress ulceration after trauma.

Prophylaxis for stress ulceration is considered standard care for most critically ill patients, but may be overutilized. We determined the incidence of stress ulceration in 33,637 major trauma patients treated in a regionalized trauma system from 1985 to 1991 using trauma registry data and chart review. Injury-related risk factors for stress ulceration and other associated infectious and organ failure complications were identified by regression analysis. Clinical stress ulceration developed in 57 patients (0.17%) despite prophylaxis. Eighteen patients (0.05%) developed severe ulceration with either gastroduodenal perforation (3 patients) or a > 2 U blood transfusion requirement (16 patients). Independent risk factors with odds ratios (OR) were identified as follows: Injury Severity Score (ISS) > or = 16, OR = 12.6; spinal cord injury, OR = 2.0; and age > 55, OR = 2.4. Other serious complications, including pneumonia, sepsis, and organ failure (adult respiratory distress syndrome and renal and hepatic failure), were significantly associated with the development of stress ulceration. Clinically significant stress ulceration after trauma is uncommon, but occurs despite prophylaxis. Severe injury (ISS > 16) and spinal cord injury were identified as independent injury-related risk factors. All patients with severe ulceration had either one of these injury-related risk factors or a significant infectious complication or organ failure. Standard prophylaxis may be inadequate in high-risk patients, who should be targeted for increased surveillance and aggressive prophylaxis. On the other hand, routine prophylaxis in low-risk patients may be overutilized.

Adolescent↗
PubMed1994

Risk factors associated with pulmonary embolism despite routine prophylaxis: implications for improved protection.

Despite prophylaxis, pulmonary embolism (PE) remains a major cause of posttraumatic morbidity and mortality in high-risk patients. We studied injury-related risk factors associated with the occurrence of PE despite routine prophylaxis. A review of 9721 trauma patients discharged from January 1, 1985 through December 31, 1992, identified 36 patients (0.4%) who suffered clinically evident PE despite a policy of routine prophylaxis against deep venous thrombosis that included use of prophylactic inferior vena caval filters. (Twenty-nine patients had an inferior vena caval filter placed for prophylaxis against PE.) A detailed analysis of injury-related risk factors was performed. Four high-risk patterns of injury were identified, representing common combinations of significant risk factors. These patient groups have an absolute risk of PE despite prophylaxis ranging from 1.5% to 3.8%. The relative risk is approximately ten times that of control patients. Identification of appropriate high-risk groups is necessary to allow optimization of prophylactic measures, including placement of inferior vena caval filter.

Adult↗
PubMed1994

The economic status of trauma centers on the eve of health care reform.

An in-depth understanding of the economic problems confronting trauma centers is essential for their continued development and to address impending changes of health care reform. A comprehensive financial and demographic survey was sent to 839 hospitals identified as potential trauma centers. A total of 313 surveys from 48 states were returned. Extensive information was collected in several areas including financial status (58% reported serious financial problems and 36% reported minor financial problems; 68% reported a financial loss), cost containment and management strategies, marketing, "halo" effect (53% reported positive effect), operational impacts, physician support (47% reported problems), malpractice (92% reported no special problem), role of auto insurance reimbursement, and access to rehabilitation. Detailed financial data of actual costs and reimbursements (95 respondents) were analyzed with the costing method used by the Health Care Financing Administration (HCFA). These data will allow us to develop better strategies to deal with the problems of uncompensated and underfunded trauma care and improve trauma center viability.

Catchment Area, Health↗
PubMed1992

Blood in our streets. The status and evolution of trauma care systems.

Injury is our nation's leading public health problem. Victims of violence need expert and immediate medical attention. A model exists for optimal care of the injured patient--the trauma care, the components of the ideal, inclusive history of trauma care, the components of the ideal, inclusive trauma care system, its efficacy, and the challenges and opportunities facing those who advocate such systems.

Humans↗
PubMed1992

An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement.

The purpose of auditing trauma care is to maintain quality assurance and to guide quality improvement. This study was conducted to identify the incidence, type, and setting of errors leading to morbidity and mortality in trauma patients. Determinations of the Medical Audit Committee of San Diego County were reviewed and classified by the authors for identification of preventable errors leading to morbidity or mortality. Errors were classified by type and categorized by phase of care. Errors were identified in the cases of 4% of all patients admitted for trauma care over a 4-year period. Of all trauma patient deaths, 5.9% were considered preventable or potentially preventable. The most common single error across all phases of care was failure to appropriately evaluate the abdomen. Although errors in the resuscitative and operative phases were more common, critical care errors had the greatest impact on preventable death. The detected error rate of 4% may represent the baseline error rate in a trauma system. While regionalized trauma care has dramatically reduced the incidence of preventable death after injury, efforts to further reduce preventable morbidity and mortality may be guided by an identification of common errors in a trauma system and their relationship to outcome.

California↗
PubMed1991

The significance of critical care errors in causing preventable death in trauma patients in a trauma system.

The regionalization of trauma care has led to a decrease in preventable death after injury. This decrease has been attributed to earlier resuscitation and surgical intervention. Little emphasis, however, has focused on the critical care phase of trauma patient management. This study was undertaken to determine the significance of critical care errors (CCEs) on preventable mortality and morbidity in a regionalized system of trauma care. The records of 12,910 trauma patients admitted to six trauma centers over a three-year period were reviewed. The cause and preventability of death was determined by a panel of trauma experts. Critical care errors occurred in 151 (23%) of all patients with errors occurring during any phase of care. The CCEs were identified in 38 of 125 (30%) deaths of patients with errors in some phase of care. The CCEs were implicated as the cause of death in 30 (48%) of the 62 preventable deaths. The proportion of preventable deaths attributable to CCEs was higher than the proportion of preventable death attributable to errors in the resuscitative and operative phases of care (p less than 0.001, chi-square). These data indicate that CCEs significantly contribute to preventable mortality and morbidity in trauma patients. It is imperative that physicians caring for trauma patients possess expertise in the critical care management of injured patients.

Cause of Death↗
PubMed1991

An analysis of the critical problem of trauma center reimbursement.

There is a widespread perception that many trauma centers are poorly reimbursed, and many hospitals that once cared for trauma victims no longer do so, primarily for financial reasons. The problem is blamed on both uninsured and underinsured patients, but data supporting this perception are lacking. To determine the validity of these perceptions and to better understand the nature of trauma center reimbursement, a survey was conducted. A questionnaire on the volume of trauma seen annually and the reimbursement experience for trauma center (TC) and hospital (HO) patient populations was mailed to representative but nonrandomly chosen trauma centers. Seventy-one surveys were mailed and 25 were returned (35%). There were 15 Level I and 10 Level II centers; 16 were urban, seven were suburban, and two were rural. Eighteen centers (72%) reported significant underfunding of the TC in contrast to the HO, and 11 indicated that they would not be able to continue their current level of TC services with present reimbursement. For Medicare patients, HO cost recovery rates averaged 93%, but recovery rates were only 64% for TCs. For Medicaid beneficiaries, the HO cost recovery rate averaged 85%, but it was only 49% for TCs. Thirty-one percent of TC patients had no insurance coverage at all, in contrast to only 9% of HO patients. An aggregate loss equal to 19.9% of total costs was reported by respondents. This survey, while not representative of trauma centers as a whole throughout the United States, does suggest that there is a basis for the perception of underfunding of trauma care and indicates that such underfunding results from the combination of adverse selection and disproportionate share. We also describe a new method for assessing and comparing trauma center reimbursement.

Data Collection↗
PubMed1990

Popliteal vascular trauma. A community experience.

Preventing amputation continues to be a significant challenge when popliteal vascular injuries occur. A retrospective review of cases from the San Diego County (California) Trauma System identified 108 patients with 76 blunt and 32 penetrating arterial injuries. The limb preservation rate was 88%; there were 13 amputations. The fracture-dislocated knee injury and close-range shotgun blasts were particularly limb threatening. In general, the trauma system achieved rapid evaluation of injuries and early operative intervention. All 13 patients who underwent amputations presented with signs of severe ischemia. Concomitant injuries to the popliteal vein, tibial nerves, and soft tissue were significantly more frequent in patients who underwent amputations. The importance of complete fasciotomy for compartment hypertension, early reconstructive management of soft-tissue injuries, and expeditious arterial repair, frequently without preoperative roentgenographic suite arteriography, is emphasized. An aggressive, multidisciplinary approach is required to achieve a functional extremity when popliteal vascular trauma occurs.

Adolescent↗
PubMed1987

Impact of a trauma system on outcome of severely injured patients.

We examined the impact of a trauma system on the survival of patients with a Trauma Score of 8 or less. We compared the observed survival with that predicted using a method that calculates the probability of survival (Ps) based on age, physiologic score, and anatomic severity of injury. Of 3394 patients triaged to trauma centers in a 12-month period, 283 (8.3%) had a Trauma Score of 8 or less. Sufficient data were available in 189 patients with blunt trauma to make the survival comparison. The Ps was 18%; the observed survival was 29%. Of 60 patients with penetrating trauma and complete data, the Ps was 8%; the observed survival was 20%. We attribute the improved survival to the integration of prehospital and hospital care and expeditious surgery.

Adult↗
PubMed1987

Regional trauma system design: critical concepts.

Regional trauma system implementation is proceeding in a number of areas of the United States in response to a demonstrated need for improved trauma care to prevent unnecessary death. The critical questions underlying the design of such systems and the current state of knowledge and opinion regarding each of them have been defined and these provide a framework for system planning. Additional data are badly needed in several areas to provide a more rational basis for system configuration. It is hoped that systems currently being implemented will include appropriate data elements in their trauma registries to answer the remaining questions in succeeding years.

Health Facility Planning↗
PubMed1987

Assuring quality in a trauma system--the Medical Audit Committee: composition, cost, and results.

A multidisciplinary concurrent audit of the quality of medical care within a trauma system was carried out by a committee of physicians, nurses, and health officials representing trauma centers, nontrauma hospitals, and the public agency administrating the trauma system. Care was audited with regard to timeliness and appropriateness of diagnosis and therapy. Complications were classified as being due to an error in diagnosis, judgment, or technique. Deaths were classified as nonpreventable, potentially salvageable, or frankly preventable. During the first 22 months of operation (1 August 1984-30 May 1986), 7,936 cases were audited. Of the 224 deaths occurring at nontrauma hospitals, 17 (7.6%) were felt to be frankly preventable. Of 541 deaths occurring at trauma centers, 11 (2.0%) were felt to be frankly preventable (p less than 0.001). The most common problem implicated in preventable deaths at nontrauma center hospitals was an error in diagnosis. Preventable deaths at trauma centers were most commonly due to an error in technique. Complications or protocol violations occurred in 595 of 6,564 surviving trauma patients (9.1%). During the first 12 months of system operation, 7,200 person-hours were required to perform the audit. Personnel costs alone for audit in the first year were $300,420.

California↗
PubMed1986

Extraperitoneal approach for aortoiliac reconstruction of the abdominal aorta.

The extraperitoneal approach is not usually used for reconstruction of the abdominal aorta; however, herein we have made an attempt to influence vascular surgeons to modify this practice. The results in 200 patients approached extraperitoneally have been compared with those of 70 patients explored by the traditional transperitoneal route. The expeditious technique of extraperitoneal exploration described results in significantly less postoperative morbidity due to the pulmonary complications of atelectasis and pneumonia. Intestinal ileus is uniformly brief, and rarely requires nasogastric suction. Patients explored extraperitoneally have demonstrably less pain and were discharged from the hospital sooner. Furthermore, prosthetic graft patency and mortality were comparable in both groups. Thus, the retroperitoneal approach should be the preferred method of aortoiliac reconstruction since the postoperative convalescence period is smoother and shorter.

Aged↗
PubMed1986

The effect of regionalization upon the quality of trauma care as assessed by concurrent audit before and after institution of a trauma system: a preliminary report.

To assess the need for a trauma system in San Diego County, a concurrent audit of trauma care was performed by an independent consultant in 1982. During the study period from 15 March through 15 June 1982, 591 consecutive major trauma victims (MTV) were collected by the 30 participating hospitals. All medical records, including autopsy reports, were audited for the timeliness and appropriateness of diagnosis and definitive care. Deaths were classified as being not preventable, potentially salvageable, or preventable. A trauma system subsequently became functional on 1 August 1984, with five adult centers and one pediatric center. A Medical Audit Committee composed of physicians and nurses from designated and nondesignated hospitals was organized to perform a monthly concurrent audit of trauma care. Between 1 August and 31 December 1984, 1,366 MTV were triaged to trauma centers. The care of MTV was considered suboptimal in 32% of patients before regionalization, compared to 4.2% after regionalization (p less than 0.01). Preventable deaths occurred in 13.6% of fatalities occurring before implementation of a trauma system, compared to 2.7% after implementation (p less than 0.01). Regionalization of trauma care significantly reduced delays, inadequate care, and preventable deaths due to trauma.

Adolescent↗