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W S Copes

Publications and source records attributed to W S Copes.

At least 19 recordsLinked to original sources
PubMed1999

Case-matching methodology as an adjunct to trauma performance improvement for evaluating lengths of stay and complications.

OBJECTIVE: To apply case-matching methodology to a statewide trauma registry to identify for peer review one trauma center's patients with "unexpected" survival deaths, complications or prolonged length of stay in hospital (H-LOS) or in Intensive Care Unit (ICU-LOS). METHODS: Matching patients were defined by mechanism of injury, age, physiology and intubation status on emergency department admission, preexisting conditions, and the pattern and severity of anatomic injury. Matches for one trauma center's 1997 patients (TCP) were sought from other centers' patients (SWP) submitted to the statewide registry from October 1, 1993, though December 31, 1997. A minimum of 20 SWP matches was required for creating a matching group. TCP were compared with matching SWP for survival, H-LOS, and ICU-LOS and the occurrence of complications. Unexpected survivors and deaths identified by matching (by using the standard 50% cutpoint) were also evaluated by TRISS and the American College of Surgeon's Committee on Trauma. A patient whose complications occurred in less than 10% of matching patients or whose H-LOS or ICU-LOS exceeded the 90th percentile of its matching SWP were also designated for peer review. RESULTS: The potential matching pool included 69,660 SWP. At least one SWP match was found for 565 (92.9%) of the 608 TCPs. The average, median, and maximum number of matches were 917.6, 235, and 6,504 patients, respectively. The 451 patients with 20 or more SWP matches were further studied. Case matching and TRISS agreed on the identification of five unexpected deaths; the American College of Surgeon's Committee on Trauma agreed on four of five. Peer review included, however, that none of the deaths were clinically unexpected. Case matching identified 14 TCP with 29 complications; only 4 of those patients had undergone concurrent peer review. Retrospective review revealed two preventable and potentially seven preventable complications. There were 35 TCP patients with prolonged H-LOS and 24 with prolonged ICU-LOS. Peer review of those cases identified that complications and problems related to discharge planning contributed to the prolonged ICU-LOS (20.8% and 25.0%) and the H-LOS (20.% and 48.6%), respectively. CONCLUSION: Peer review of patients identified by case-matching methodology uncovered opportunities for system improvement that were missed by the concurrent performance improvement process. This method may also allow identification of anticipated H-LOS and ICU-LOS to promote earlier discharge.

Adolescent↗
PubMed1998

Automated coding of injuries from autopsy reports.

Medical examiners have a unique database about trauma victims, many, if not most, of whom died at the scene or in transit to a hospital and who, thus, never had their injuries documented by trauma surgeons and so never entered into a local or regional trauma registry. These trauma registries have assisted in assessing the magnitude of traumatic injuries in the community and in evaluating the community's emergency medical systems. Without information about those who are dead at the scene or who die in transit, these trauma registries are incomplete and the evaluations based on them inaccurate. The data about the 50% of trauma victims who never enter the medical system are lacking in these registries. Such information is present in the death investigation and autopsy reports in the various medical examiner/coroner offices in the country. To access this important information more easily in trauma registries, an expert computer system was developed. This pilot study presents the results of using that system to gather medical examiner data. Injury descriptions were abstracted from autopsy reports of 50 consecutive nonhospitalized persons fatally injured in Mobile County, Alabama and its environs. Injury descriptions for all cases were successfully coded in International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) and the Abbreviated Injury Scale (AIS-90) by an expert system. For some cases the expert system "requested" and received clarifying information, all of which was present in the medical records. This research demonstrates the feasibility of gathering accurate and consistent information on the estimated 50% of trauma deaths who do not reach a hospital and who are not included in acute care registries. Without data on such patients, our evaluation of trauma systems is incomplete and resources directed at prevention and treatment may be misapplied.

Abbreviated Injury Scale↗
PubMed1996

Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation.

OBJECTIVE: In 1986, data from 25,000 major trauma outcome study patients were used to relate Trauma and Injury Severity Score (TRISS) values to survival probability. The resulting norms have been widely used. Motivated by TRISS limitations, A Severity Characterization of Trauma (ASCOT) was introduced in 1990. The objective of this study was to evaluate and compare TRISS and ASCOT probability predictions using carefully collected and independently reviewed data not used in the development of those norms. DESIGN: This was a prospective data collection for consecutive admissions to four level I trauma centers participating in a major trauma outcome study. MATERIALS AND METHODS: Data from 14,296 patients admitted to the four study sites between October 1987 through 1989 were used. The indices were evaluated using measures of discrimination (disparity, sensitivity, specificity, misclassification rate, and area under the receiver-operating characteristic curve) and calibration [Hosmer-Lemeshow goodness-of-fit statistic (H-L)]. MEASUREMENTS AND MAIN RESULTS: For blunt-injured adults, ASCOT has higher sensitivity than TRISS (69.3 vs. 64.3) and meets the criterion for model calibration (H-L statistic < 15.5) needed for accurate z and W scores. The TRISS does not meet the calibration criterion (H-L = 30.7). For adults with penetrating injury, ASCOT has a substantially lower H-L value than TRISS (20.3 vs. 138.4), but neither meets the criterion. Areas under TRISS and ASCOT ROC curves are not significantly different and exceed 0.91 for blunt-injured adults and 0.95 for adults with penetrating injury. For pediatric patients, TRISS and ASCOT sensitivities (near 77%) and areas under receiver-operating characteristic curves (both exceed 0.96) are comparable, and both models satisfy the H-L criterion. CONCLUSIONS: In this age of health care decisions influenced by outcome evaluations, ASCOT's more precise description of anatomic injury and its improved calibration with actual outcomes argue for its adoption as the standard method for outcome prediction.

Adolescent↗
PubMed1996

Linking data from national trauma and rehabilitation registries.

OBJECTIVE: To evaluate te feasibility of retrospectively creating a data base useful in trauma systems evaluations. MATERIALS AND METHODS: Records for 375 patients in both the Major Trauma Outcome Study and the Uniform Data System for Medical Rehabilitation were linked to create an injury-through-rehabilitation data base, including patients from four impairment groups: traumatic brain injury (TBI); spinal cord injury --paraplegic complete (SCI-PARA) and quadriplegic complete (SCI-QUAD); and hip fracture (HIP-FX). MEASUREMENTS AND MAIN RESULTS: The average ages (25.1 years SCI-QUAD, 72.6 years HIP-FX); Injury Severity Score (10.2 HIP-FX, 31.7 SCI-PARA); Revised Trauma Score (5.9 TBI, 7.8 HIP-FX); and acute care lengths of stay (13.3 days HIP-FX, 24.2 days TBI) varied substantially over the four groups. On average, patients spent from approximately 20 days (HIP-FX) to nearly 100 days (SCI-QUAD) in rehabilitation. Functional gains during rehabilitation were primarily in motor skills, but TBI patients also made substantial cognitive gains. Nearly 90% of TBI and SCI patients were discharged to their homes; the percentage of HIP-FX patients discharged to their homes, however, was lower (74%). Across all impairment groups, more patients lived with their relatives after rather than before injury. The correlation between a summary Major Trauma Outcome Study-Functional Independence Measure assessed at acute care discharge and the complete Uniform Data System for Medical Rehabilitation-Functional Independence Measure assessed on admission to rehabilitation was significant for all study patients and for each impairment group except SCI_PARA. CONCLUSIONS: Linking records to create the study data base was arduous and could not be practically accomplished on a large scale or on a continuing basis. Because of the growing emphases on trauma system evaluations and outcomes beyond survival at acute care discharge, we recommend the routine inclusion of rehabilitation data in hospital-based trauma registries.

Activities of Daily Living↗
PubMed1995

Institution and per-surgeon volume versus survival outcome in Pennsylvania's trauma centers.

BACKGROUND: The American College of Surgeons recommends minimum patient volumes for trauma centers and surgeons. Those numbers, however, are largely based on results from studies of surgical (but not trauma) relationships between volume and outcome. METHODS: Using stepwise regression, relationships were sought between measures of patient volume per trauma center and per surgeon and ana severity-controlled measure of survival outcome (W). For significant z values, W is the number of additional (or fewer) survivors, per 100 patients treated, than expected from ASCOT norms. W = 0 when z is nonsignificant. Data are from patients admitted in 1988 and 1989 to accredited Pennsylvania trauma centers. RESULTS: The relationships found for all patients and for adult blunt-injured patients are W = 0.3312 + 0.0200 (NSER/SURG) and W = 0.3638 + 0.0248 (NBSER/SURG), respectively, where NSER/SURG is the number of seriously, injured patients treated annually per surgeon and NBSER/SURG is the number of adult patients with serious blunt injuries treated annually per surgeon. Serious injury was defined, using the Injury Severity Scale, as > = 13 or, using the Abbreviated Injury Scale, as a head injury of > = 3. The relationships explained 36% and 61% of the variance in W (R2 for all patients and adult blunt-injured patients, respectively. To achieve normative survival (W =0), 95% confidence intervals suggest that a trauma surgeon should treat at least 35 seriously injured patients per year and at least 28 adult patients with serious blunt injury annually. No volume-related variable was a significant contributor to predictions of W for adult patients with penetrating injuries or for pediatric patients. CONCLUSIONS: These results support the regionalization of trauma care by affirming that increased per-surgeon experience in the treatment of seriously injured patients is associated with improved outcomes and help define the minimum experience needed to achieve normative survival. Prospective study of the relationship between volume and survival and other outcomes is required.

Adult↗
PubMed1995

American College of Surgeons audit filters: associations with patient outcome and resource utilization.

OBJECTIVE: To determine if trauma patients qualifying by a 1990 American College of Surgeons (ACS) audit filter have the same outcomes and resource utilizations as similar (matching) patients not qualifying by the filter. DESIGN: Retrospective, case control study. MATERIALS AND METHODS: Data for 21,175 patients submitted during 1992 to the Pennsylvania Trauma Outcome Study (PTOS) were analyzed. Patients qualifying by each 1990 ACS audit filter were identified, except filters 13 and 22 that were not accommodated by the PTOS form. In addition, qualifiers by filter 21 (trauma deaths) were not analyzed. For each qualifier by a filter, matching patients who were not qualifiers by the filter were identified. Matching patients had the same cause of injury, A Severity Characterization of Trauma (ASCOT) age category, distribution of serious (Abbreviated Injury Score of > 2) injuries, intubation status, and coded Revised Trauma Score values on Emergency Department arrival. Qualifiers and matching patients were compared for their survival (z and W statistics), discharge disability (PTOS-Functional Independence Measure), and lengths of stay in the hospital (H-LOS) and in the Intensive Care Unit (ICU-LOS). MEASUREMENTS AND MAIN RESULTS: More than 57% of the study sample qualified by one or more filters. Filters 10 and 12 did not have sufficient qualifiers for evaluation. No filter's qualifiers were associated with significantly more disability at discharge than matching patients. The most frequently occurring filters (4, 2, and 5, respec-tively) deal with documentation deficiencies, but were not associated with significant results. Qualifiers by the nine filters below were associated with significantly greater mortality or H-LOS or ICU-LOS. [table: see text] CONCLUSIONS: Additional studies of the efficacy and efficiency of trauma quality assurance filters are needed. Objective criteria should be established for the definition, evaluation, modification, and adoption of trauma audit filters.

Adult↗
PubMed1994

An evaluation of expert human and automated Abbreviated Injury Scale and ICD-9-CM injury coding.

Two hundred ninety-five injury descriptions from 135 consecutive patients treated at a level-I trauma center were coded by three human coders (H1, H2, H3) and by TRI-CODE (T), a PC-based artificial intelligence software program. Two study coders are nationally recognized experts who teach AIS coding for its developers (the Association for the Advancement of Automotive Medicine); the third has 5 years experience in ICD and AIS coding. A "correct coding" (CC) was established for the study injury descriptions. Coding results were obtained for each coder relative to the CC. The correct ICD codes were selected in 96% of cases for H2, 92% for H1, 91% for T, and 86% for H3. The three human coders agreed on 222 (75%) injuries. The correct 7 digit AIS codes (six identifying digits and the severity digit) were selected in 93% of cases for H2, 87% for T, 77% for H3, and 73% for H1. The correct AIS severity codes (seventh digit only) were selected in 98.3% of cases for H2, 96.3% for T, 93.9% for H3, and 90.8% for H1. On the basis of the weighted kappa statistic TRI-CODE had excellent agreement with the correct coding (CC) of AIS severities. Each human coder had excellent agreement with CC and with TRI-CODE. Coders H1 and H2 were in excellent agreement. Coder H3 was in good agreement with H1 and H2. However, errors among the human coders often occur for different codes, accentuating the variability.(ABSTRACT TRUNCATED AT 250 WORDS)

Abbreviated Injury Scale↗
PubMed1994

Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries.

An analysis of the completed Major Trauma Outcome Study (MTOS) data set was undertaken to compare the incidence, mortality, morbidity, and injury severity of patients with head injuries (HI) with those of patients with extracranial injuries (ECI). The MTOS was completed recently after data from 174,160 patients submitted from 165 trauma centers from 1982 through 1989 were collated and validated. Data were analyzed with regard to the effect of injury causation for vehicular-related, nonvehicular-related, and penetrating injuries for patients with HI, ECI, or both. Detailed analyses of relationships between AIS-85 and Glasgow Coma Scale score from the entire data base, and between discharge status, functional independence measures (FIM scores), and severity of HI and ECI in a subset of 70,000 surviving patients were performed. Vehicular-related injuries (49.7%) were divided into those to vehicle occupants (36.4%), pedestrians (7.2%), and motorcyclists (6.0%). Nonvehicular-related blunt injuries included falls (18.4%) and assaults (13.2%) and penetrating injuries consisted of gunshots (8.7%), stabbings (8.0%), and other penetrations (1.8%). There were 59,713 patients with HI (34%) and 114,447 with no head injuries (NHI) (66%). Vehicular causes produced more HI (66.6%) than all other causes, despite the preponderance of nonvehicular-related HI in the overall series (50.3%). The overall MTOS mortality rate was 8.3%, but was three times higher in the HI group (14.5%) than in the NHI patients (5.1%). Injury severity measured by AIS-85 had, as expected, a profound influence on mortality of both HI and NHI groups. A similar high correlation was found between Glasgow Coma Scale score and mortality for head injured patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Craniocerebral Trauma↗
PubMed1994

Status of trauma patient management as measured by survival/death outcomes: looking toward the 21st century.

Since the focus of trauma care is to improve survival and norms have been established through large database studies to evaluate outcomes, the Relative Outcome Score provides a method to gauge treatment outcomes against perfection, on an ongoing basis, as long as baseline and severity mixes are standardized. The ROS will probably never reach 1.0 and may eventually plateau as treatment abilities are maximized for trauma patients, but the ROS does at least provide a measure to compare with the past, present and future.

Humans↗
PubMed1994

Determining normative standards for functional independence measure transitions in rehabilitation.

We present a method for determination of normative standards for Functional Independence Measure (FIM) transitions in rehabilitation. Data from 230 consecutive brain-injured patients treated before 1991 were used to characterize transitions in patient FIM values between admission and discharge. The pre-1991 average and standard deviation FIM transitions, computed as a function of admission values, are used as standards ("norms") for comparing rehabilitation transitions among institutions or in one institution over time (say, yearly) and for identifying patients with striking transitions, believed worthy of audit. The evaluation method requires the computation of two statistics, z and W, which compare the actual transitions for patients of one time period (in this instance the 1991 patients) to the expected transitions as computed from the pre-1991 norms. The z and W values indicated that 1991 transitions were neither statistically nor clinically different from pre-1991 ones. Also introduced in the paper are the concepts of Mean Gain, Ideal Gain, and the ratio Mean Gain/Ideal Gain. Ideal Gain is the greatest possible "aggregated" transitions score for a study patient set and the ratio Mean Gain/Ideal Gain may be interpreted as "the degree of ideal rehabilitation transitions achieved."

Activities of Daily Living↗
PubMed1993

Pediatric coefficients for TRISS analysis.

We computed regression coefficients for TRISS analysis for all 4271 pediatric patients (aged 1 through 14 years) with complete data from the Major Trauma Outcome Study. We then compared predicted pediatric and adult TRISS survival probability norms. There were no statistically significant differences in the predicted and actual numbers of survivors using either norm. Differences in discrimination and reliability between the two norms were minimal. The study confirmed that the TRISS adult blunt norm is highly discriminating and reliable in predicting survival probabilities for pediatric patients. Given that both norms were equally good predictors, and the importance of a consistent system to evaluate trauma care, the authors recommend the continued use of the adult blunt trauma norm for estimating survival probability in children.

Adolescent↗
PubMed1993

Effect of preinjury illness on trauma patient survival outcome.

UNLABELLED: Data from 11,156 patients treated at the four Major Trauma Outcome Study controlled sites were used to estimate the effect on survival of each APACHE II preinjury illness condition (PIC). A case-control methodology was applied; 544 patients (4.8%) had one or more PICs. For each patient with a specific PIC we identified a set of matching patients with no PICs. A patient matches a PIC patient if both have the same mechanism of injury, the same coding of Revised Trauma Score variables (Glascow Coma Scale score, systolic blood pressure, respiratory rate), the same coded age per A Severity Characterization of Trauma) (ASCOT), and if they differ by no more than 0.5 for A, B, and C (the ASCOT components for serious injuries). The estimated survival probability for a PIC patient is either the survival rate for the patient's matched set or, if there are no matches, the patient's ASCOT survival probability. The survival probabilities were used to compare the actual and predicted numbers of survivors for each PIC, using z and W statistics. Computations of z and W were also made using ASCOT survival probabilities for each PIC patient. The results indicate profound effects of five PICs (hepatic, cardiovascular, respiratory, renal, diabetes) on trauma patient outcomes. CONCLUSION: Pre-existing organ dysfunction has a profound effect on patient outcome even after controlling for age, anatomic and physiologic severity, and mechanism of injury. But, because of their relatively low incidence in this sample, PICs did not strongly influence institutional outcome performance as measured by z and W values.

Adolescent↗
PubMed1993

Avoiding complications of long-term venous access.

Indwelling venous catheters are invaluable for long-term chemotherapy, antibiotics, and hyperalimentation. However, their placement and chronic use can cause serious complications. This study was done to develop guidelines for minimizing complications of long-term vascular access. Complications associated with 355 lines placed in 297 patients were recorded prospectively at the George Washington University Hospital. Single or double lumen catheters were placed via the infraclavicular subclavian approach (126), external jugular cutdown (133), internal jugular cutdown (22), and cephalic vein cutdown (42). While catheters were malpositioned in 15 cases (5.2%), route of placement did not influence this adverse outcome. Pneumothorax occurred only in the subclavian approach (5.6%). Axillary vein thrombosis was significantly more prevalent in catheters placed via the subclavian vein (10.3%) compared with the external jugular (2.3%) P < 0.05 or cephalic (2.3%) vein. Line sepsis occurred in 28 instances; this was statistically associated with an abnormal white blood count and with the use of double-lumen catheters (double-lumen catheter sepsis = 18.4%, single lumen = 4.4%, P < 0.01). The morbidity of long-term venous catheters is affected significantly by the route of placement, the number of catheter lumens, and the pre-placement white blood count. As a result of our analysis, we recommend single-lumen catheter placement using the external jugular cutdown route whenever possible.

Adult↗
PubMed1992

Improvement in outcome from trauma center care.

Survival and death outcomes for patients with blunt injuries treated at one urban hospital were evaluated during a 6-year period of increasing commitment to trauma care, as evidenced by the construction of a resuscitation facility with integrated operating rooms. Patient survival, when controlled for severity mix, showed a trend of improvement during the study period. Improvement in survival outcome was more notable after the opening of the trauma resuscitation facility and among the more severely injured. When data from years 1 and 2 combined were compared with those from years 5 and 6, a statistically significant difference in survival was found, with an average of 13.44 more survivors per 100 patients treated per year with Injury Severity Scores greater than 15.

District of Columbia↗
PubMed1992

Differences in trauma care among pediatric and nonpediatric trauma centers.

To characterize pediatric trauma care, state trauma registry data from all designated trauma centers in Pennsylvania were divided into three categories, that from: (1) pediatric centers, (2) urban nonpediatric centers, (3) and rural nonpediatric centers. From October 1, 1986 through September 30, 1989 (3 years), 4,615 patients less than 15 years old were admitted to 28 trauma centers in Pennsylvania. Nonpediatric centers cared for the majority of children (2,734, 59.2%), but the average number of children treated per nonpediatric institution (105.1 per year) was far fewer than the average treated in the pediatric centers (940.5). Pediatric trauma centers in the state treated a younger population (6.4 +/- 4.2 years, mean +/- SD) compared with urban and rural nonpediatric centers (8.4 +/- 4.2 and 8.1 +/- 4.3 years, respectively; P less than .05). Pediatric centers received proportionately more children by transfer (56.2%), victims of falls (34.6%), pedestrian injuries (16.8%), and head and neck injuries (41.8%, all P less than .05). Nonpediatric centers received children directly from the scene of injury more frequently than transferred from other hospitals. The male:female sex ratio in urban nonpediatric centers was significantly higher (70.1%, P less than .05) than in the other two groups. Rural nonpediatric centers cared for a higher proportion of motor vehicle passengers (28.5%) and patients classified as "other" in the state registry, a category to which bicycle injuries are assigned (28.2%, P less than .05). Mortality was highest in rural nonpediatric centers (6.2%). The death rate in pediatric centers and urban nonpediatric centers were similar (4.1%) and significantly lower (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

TRISS unexpected survivors--a statistical phenomenon or a clinical reality?

Data from patients treated in Pennsylvania-accredited trauma centers during 1989 were analyzed. TRISS expected and unexpected survivors (1.6% of all survivors) differed in many ways. Unexpected survivors were more than twice as likely to have been transferred from a nondesignated trauma center (45.8% vs. 22.8%, p < 0.001). Unexpected survivors had significantly higher frequencies of motor vehicle injuries (56.2% vs. 38.3%, p < 0.001), pedestrian injuries (9.6% vs. 5.4%, p < 0.01), and gunshot wounds (7.3% vs. 4.7%, p < 0.01). Expected survivors were injured more frequently in falls (26.1% vs. 10.8%, p < 0.001) and were less frequently male (64.5% vs. 75%, p < 0.001). Unexpected survivors had significantly longer average hospital stay (29.6 s vs. 9.3 days, p < 0.001) and more frequent (98.8% vs. 36.8%, p < 0.001) and longer average stays in the ICU (13.3 s vs. 4.1 days, p < 0.001). The percentage of unexpected survivors discharged to rehabilitation centers (61.9%) was significantly greater than that for expected survivors (8.7%), (p < 0.001). Unexpected survivors were more frequently judged "completely dependent" in five measures of functional disability than expected survivors. We conclude that unexpected survivors are a seriously injured and clinically relevant patient set, not just a statistical phenomenon.

Activities of Daily Living↗
PubMed1992

Results of a multi-institutional outcome assessment: results of a structured peer review of TRISS-designated unexpected outcomes.

The utility of TRISS as a component of trauma center quality assurance (QA) was evaluated. TRISS survival probabilities were estimated for a total of 2,023 consecutive trauma patients admitted to three level-I trauma centers during a 6-month period. A structured peer review was performed of the 50 patients (2.1%) having statistically unexpected outcomes. For 23 (18 survivors, five deaths) TRISS-designated outcomes were sustained in peer review. In 27 cases (one survivor, 26 deaths) TRISS-designated outcomes were not sustained by peer review and TRISS. Limitations were identified in each case. Peer review of unexpected outcomes identified by TRISS provided a consistent and objective QA methodology. An understanding of TRISS as an objective component of the trauma center QA process is essential in blending it with what is, at present, a largely subjective process in many hospitals. Use of TRISS standardizes the peer review process, resulting in a more reliable base for development and improvement of trauma center QA programs.

Adolescent↗