Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

doi:10.1016/j.injury.2016.10.037

Injury

Volume 48, Issue 1, January 2017, Pages 5-12

https://doi.org/10.1016/j.injury.2016.10.037 Get rights and content

Abstract

Background

Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center.

Methods

Records at an urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05.

Results

7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p < 0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 h. Unadjusted mortality dropped from 7.0% to 6.1 (p = 0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p < 0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1).

Conclusions

Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.

Section snippets

Methods

The trauma registry, weekly Morbidity & Mortality reports, autopsy reports and electronic medical records at Memorial Hermann Hospital in Houston, TX were reviewed. The Memorial Hermann Hospital is one of two level 1-trauma centers serving the greater Houston area and admits greater than 6000 injured patients a year.

Two time periods (2005–2006 and 2012–2013) were included in the analysis. These periods of time represent two years before and after implementation of major changes in control of

Results

We reviewed 15,874 and 1029 deaths from the 4-year study period. 7080 patients including 498 deaths were examined in the early time period (2005–2006), while 8767 patients including 531 deaths were reviewed in the recent period (2012–2013). There was a 23% increase in the number of admissions in the recent period. The overall trauma population showed differences in age and gender overtime but were similar in race/ethnicity distribution (Table 1). The median age of all patients increased by 6

Discussion

World wide, injury-related deaths has increased by 24% (1990–2010) [6], [7] while US data shows a 23% increase in death rate due to trauma over the past decade (2000–2010) [5], [6]. Dutton et al. [2010] in a similar single-site study showed an increase in mortality over time (1997–2008) [9]. However the data at our single-site study demonstrates a significant reduction in adjusted overall and in-hospital mortality. While our data does not reflect the entire population of the greater Houston

Conclusion

Injury is a leading cause of mortality in the US and around the world. The dominant causes of death are TBI and hemorrhage. In this single center retrospective study, we demonstrated a reduction in hemorrhagic death rates, while TBI and MOF/sepsis rates remained unchanged. This change was likely associated with implementing a multimodal bleeding control bundle of care, rather than any one specific intervention. Adequate funding for high quality prehospital and early hospital based intervention

Financial support

The Center for Translational Injury Research and The University of Texas Medical School at Houston- Office of the Dean.

Disclosure statement

The authors have nothing to disclose.

Acknowledgments

This study is supported by the Center for Translational Injury Research and The University of Texas Medical School at Houston Office of the Dean.

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Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusion

Financial support

Disclosure statement

Acknowledgments

Am J Prev Med

Lancet

Injury

J Emerg Med

J Emerg Med

J Am Coll Surg

Injury

Mortality in the United States, 2012

NCHS Data Brief

Cancer statistics, 2013

CA Cancer J Clin

Heart disease and stroke statistics—2014 update: a report from the American Heart Association

Circulation

Increasing trauma deaths in the united states

Ann Surg

Injuries

N Engl J Med

?Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997–2008

J Trauma

Epidemiology of trauma deaths: a reassessment

J Trauma

Transforming from centers of learning to learning health systems

JAMA

Damage control resuscitation: directly addressing the early coagulopathy of trauma

J Trauma

Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive truama patients

Ann Surg

Damage control resuscitation: from emergency department to the operating room

Am Surg

Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients

Ann Surg