An Analysis of In-Hospital Deaths at a Modern Combat Support Hospital

Abstract

Analysis of the epidemiology and attribution of in-hospital deaths is a critical component of learning and process improvement for any trauma center. We sought to perform a detailed analysis of in-hospital deaths at a combat support hospital. All patients with trauma who survived to admission and subsequently died before transfer or discharge during a 1-year period were included. The timing, location, pathogenesis, and circumstances surrounding the death were recorded. Opportunities for improvement (OI) of care were identified for analysis. Cases were presented to a panel of experts, and preventability of the deaths was scored on a continuous 10-point scale. There were 151 deaths, with the predominant mechanisms of gunshot wounds (GSW) (47%) and blast injuries (42%). Most had severe injuries, with a mean Injury Severity Score of 38, pH of 7.09, and base deficit of 12. Predominant causes of death were head injury (45%) and hemorrhage (32%), and 78% died within 1 hour of admission. Most deaths occurred during the intensive care (35%) or resuscitation phases (31%), but the majority of deaths among nonexpectant patients occurred during the operative phase (38%). OI were identified in 74 deaths (49%), and were found in 78% of nonexpectant deaths. Most improvement opportunities occurred during the resuscitation and transport phases. Most potential improvements were identified at the system level (54%) or individual provider level (42%). Preventability scoring showed excellent inter-rater reliability (r = 0.92, p < 0.001). Deaths with high preventability scores (mean >54) were primarily related to delays in hemorrhage control during the transportation (47%) or resuscitation (43%) phases, and attributed to the system (63%) and individual provider levels (70%). In-hospital combat trauma-related deaths at a modern Combat support hospital differ significantly from their civilian counterparts, and present multiple OI of care and potential salvage. Delays in prehospital and in-hospital hemorrhage control are the primary contributors to potential preventability.