Peer review audit of trauma deaths in a developing country

Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.
Asian Journal of Surgery (Impact Factor: 0.91). 02/2004; 27(1):58-64. DOI: 10.1016/S1015-9584(09)60247-5
Source: PubMed


Peer review of trauma deaths can be used to evaluate the efficacy of trauma systems. The objective of this study was to estimate teh proportion of preventable trauma deaths and the factors contributing to poor outcome using peer review in a tertiary care hospital in a developing country.
All trauma deaths during a 2-year period (1 January 1998 to 30 December 1998) were identified and registered in a computerized trauma registry, and the probability of survival was calculated for all patients. Summary data, including registry information and details of prehospital, emergency room, and definitive care, were provided to all members of the peer review committee 1 week before the committee meeting. The committee then reviewed all cases and classified each death as preventable, potentially preventable, or non-preventable.
A total fo 279 patients were registered in the trauma registry during the study period, including 18 trauma deaths. Peer review judged that six were preventable, seven were potentially preventable, and four were non-preventable. One patient was excluded because the record was not available for review. The proportion of preventable and potentially preventable deaths was significantly higher in our study than from developed countries. Of the multiple contributing factors identified, the most important were inadequate prehospital transfer, limited hospital resources, and an absence of integrated and organized trauma care. This study summarizes the challenges faced in trauma care in a developing country.

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    • "The undue delay in the referred group was due to the multiple referrals and unnecessary distances traveled due to lack of triage and transfer protocols. This chaos in prehospital care is expected as no national or regional guidelines exist for triage, patient-delivery decisions, prehospital treatment plans, and inter hospital transfer protocol in India[1] and other developing countries like Pakistan.[34] Unfortunately, development of prehospital and institutional trauma care does not always grow in a coordinated manner.[8] "
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    ABSTRACT: The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality. To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations. A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center. The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care. Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.
    Journal of Emergencies Trauma and Shock 07/2013; 6(3):164-70. DOI:10.4103/0974-2700.115324
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    • "Pakistan is a developing country in need of effective emergency medical care [5,6]and data from Pakistan clearly indicates this need. According to a study on the burden of disease in Pakistan diarrhea, lower respiratory infections, ischemic heart disease, septicemia, and injuries are among the top 15 causes of premature deaths [7]. "
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    ABSTRACT: Emergency Medical Care is an important component of health care system. Unfortunately it is however, ignored in many low income countries. We assessed the availability and quality of facility-based emergency medical care in the government health care system at district level in a low income country - Pakistan. We did a quantitative pilot study of a convenience sample of 22 rural and 20 urban health facilities in 2 districts - Faisalabad and Peshawar - in Pakistan. The study consisted of three separate cross-sectional assessments of selected community leaders, health care providers, and health care facilities. Three data collection instruments were created with input from existing models for facility assessment such as those used by the Joint Commission of Accreditation of Hospitals and the National Center for Health Statistics in USA and the Medical Research Council in Pakistan. The majority of respondents 43/44(98%), in community survey were not satisfied with the emergency care provided. Most participants 36/44(82%) mentioned that they will not call an ambulance in health related emergency because it does not function properly in the government system. The expenses on emergency care for the last experience were reported to be less than 5,000 Pakistani Rupees (equivalent to US$ 83) for 19/29(66%) respondents. Most health care providers 43/44(98%) were of the opinion that their facilities were inadequately equipped to treat emergencies. The majority of facilities 31/42(74%) had no budget allocated for emergency care. A review of medications and equipment available showed that many critical supplies needed in an emergency were not found in these facilities. Assessment of emergency care should be part of health systems analysis in Pakistan. Multiple deficiencies in emergency care at the district level in Pakistan were noted in our study. Priority should be given to make emergency care responsive to needs in Pakistan. Specific efforts should be directed to equip emergency care at district facilities and to organize an ambulance network.
    BMC Emergency Medicine 02/2008; 8(1):8. DOI:10.1186/1471-227X-8-8
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    ABSTRACT: Trauma is an increasingly significant health problem globally, especially in low-income and middle-income countries. Trauma care is often compromised by economic restrictions. Many capable individuals are attempting to meet this challenge in their own countries, however. This review summarizes such efforts and assesses how they might be expanded in a comprehensive, global fashion. Options for improving trauma care in the prehospital setting have been explored, including strengthening existing, basic formal emergency medical services (including ambulances); instituting new formal emergency medical services, where none had previously existed; and exploring novel ways to strengthen existing, although informal, systems of prehospital care when formal emergency medical services would be unfeasible. Affordable ways by which to strengthen hospital care have been addressed for several specific injuries, including open fractures, burns, and vascular injuries. Especially notable are growing efforts to better monitor outcomes and address factors contributing to preventable deaths. The Essential Trauma Care Project has defined and promoted core essential trauma care services that every injured person in the world realistically can and should be able to receive. This project is a collaborative effort of the World Health Organization and the International Society of Surgery. Individual efforts must be built upon to make progress in a comprehensive, global fashion. This review summarizes the background, achievements, and future potential of the Essential Trauma Care Project and several related efforts.
    Current Opinion in Critical Care 01/2006; 11(6):568-75. DOI:10.1097/01.ccx.0000186373.49320.65 · 2.62 Impact Factor
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