Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU

Traumatic injuries are a major cause of death and disability. Worldwide, almost 10% of all deaths are related to trauma [1]. Over the last decades, improvements in trauma care in the fields of prehospital care, emergency department (ED) care, operation techniques and intensive care led to a constant reduction of mortality rates [2, 3]. Most established quality indicators focus on the initial trauma care before and during admission [4‐6].

In general and elective surgery a number of studies suggested that a relevant proportion of patients decease within the hospital after discharge from their initial (post-operative) stay in the ICU. This group may represent potentially preventable deaths [7‐10]. To detect and treat patients on general wards with major complications in an early stage, different strategies have been developed to lower both readmission rates to the ICU and mortality [11] Early detection of patients at risk may be achieved by use of warning scores and other systematic tools of monitoring or implementation of medical emergency teams [12, 13].

Whether these aspects of improved care for surgical patients are also relevant for the care of severely injured patients is not well known. The failure to rescue (FTR) rate was described as a more precise and therefore superior characterisation of post-operative care quality than mortality or complication rates in elective surgery [14]. It was first defined in 1992 as the mortality rate among patients with complications. However it has since been rarely applied to trauma and acute care surgery [15].

In trauma patients it can be difficult or even impossible to distinguish between preventable complications and adverse events due to “natural course of the trauma”. Thus, reliable rates of failure to rescue are still lacking [16, 17]. In order to observe and measure the quality of postoperative care, an approach could be to analyse severely injured trauma patients who have been discharged to the general ward and die after an initial treatment on an intensive care unit. The aim of this study was to determine the rate of late mortality, characteristics of patients and to compare late deaths with non-survivors who died during their initial ICU stay. We expect that this approach is a simple way to retrospectively identify a cohort of potentially preventable fatal complications, even if not regognized or defined during treatment and therefore eligible for quality management and benchmarking, especially in large trauma registries.

The selection process of the study patients is shown in Fig. 1. The excluded surviving patients had a mean age of 50.3 years, a mean ISS of 16.3, mean LOS on ICU was 6.3 days, and mean LOS in hospital was 16.9 days. Overall, 5481 patients were admitted to the ICU alive and died later in hospital. In total 972 (17.1%; CI95: 16.7–18.7) of these patients were discharged from the ICU to normal ward for some days. Differences in demographics, injury pattern, therapy and course in the intensive care unit between patients who died in ICU or later after initial discharge are shown in Table 1. Patients that died before ICU discharge were younger (mean age 68 vs. 77 years), more severely injured (mean ISS 30.0 ± 15 vs. 23.1 ± 12; RISC II prognosis for mortality 52.1 vs. 32.4%); length of stay in ICU was shorter (mean days 6.0 ± 9.4 vs. 10.0 ± 13.4), while living will limiting life-sustaining therapy was documented fewer (46.1 vs. 59.9%).

Of all non-surviving patients that were initially discharged from ICU, 31.5% were treated less than 3 days and 70.9% less than 8 days outside the ICU (Fig. 2). In addition to patient-related factors, we also analysed a potential difference with respect to the level of care of the trauma center (Table 2). The rate of patients dying within first ICU stay was the highest in level 1 trauma centers (84.7%; CI95: 83.6–85.9) and was the lowest in level 3 trauma centers (68.7%; CI95: 62.9–74.4).

The majority of in-hospital deaths after major trauma occurred during the initial ICU treatment period. This study showed that a relevant group (17.1%) of all non-surviving patients initially admitted to the ICU were discharged from ICU at least once and treated outside the ICU for more than 1 day.

Multiple studies focussed on in-hospital mortality after discharge from the ICU [19‐23] Pearse et al. performed a prospective observational study on mortality after surgery in Europe [9] In emergency surgery, they found a mortality rate of 11.1% of all patients initially discharged alive from ICU to normal ward. They concluded that ICU resources were not allocated to patients at greatest risk of death. A variety of factors influencing readmission rate have been identified. Several studies showed a relationship between daytime and weekday of discharge from ICU and outcome. They confirmed that unplanned discharges from the ICU during night-time and on weekends were independent risk factors for readmission to the ICU and increased mortality [19, 24, 25]. Others confirmed older age, severity of illness on the day of admission to the ICU and day of discharge from the ICU as well as comorbidities as independent risk factors [8, 26‐28]. We did not compare surviving and non-surviving patients after ICU-discharge but non-survivors with or without initial discharge from ICU. Non-survivors after initial ICU discharge were older, less severely injured and the severity of comorbidities as measured by the American Association of Anaesthesiologists Classification (ASA) [29] were higher. Interestingly, the injury pattern and the course in the ICU differed in several points: While the percentage of blunt trauma and isolated head injury did not differ relevantly, the proportion of trauma patients without head injury was much higher in non-survivors discharged from the ICU. Percentage of patients after low fall was higher in non-survivors discharged from ICU. Regarding the ICU treatment period one hypothesis could be that patients dying after ICU discharge underwent less intensive care as they were less severely injured. They may have been underestimated by the treating physicians and were discharged from the ICU prematurely. However, the mean length of stay on the ICU long (mean days on ICU: 4) as well as the days with ventilatory support (mean days ventilated: 5.8). Low fall is a known surrogate marker for frailty, predicting long-term mortality in older trauma patients [30].

In general, fatalities after the initial discharge from the ICU may be explained by either a limitation of life-sustaining intensive care treatment with palliative care outside the ICU due to a living will or by patients who were discharged from the ICU after initial recovery but suffered a late fatal complication.

The causes of mortality of these patients remained unclear. A documented living will to limit sustaining therapy was present in 60% of patients who died after discharge from the ICU. However, we couldn’t state that all of these patients actually underwent palliative care and were discharged from the ICU due to therapy limitation. A living will was also present in 46% of non-survivors who died during their initial ICU stay. Consequently, a living will to limit life-sustaining treatment did not per se lead to an ICU discharge in this setting. The ICU stay was also rather long so that we cannot assume that there was a significant number of short (e.g. 24 h) ICU try-outs for the very old critically ill patients with consecutive withdrawal of intensive care treatment in those patients with failing recovery.

After initial recovery late complications like sepsis (19.5%) and thromboembolic complications (10.4%) resulted in death of the patient. Assumed causes of death differed to typical reasons for early mortality, i.e. bleeding, head injury and organ failure in 23.4% of cases. We can only assume which other causes of death occurred as the registry data gives no more detailed information regarding the parameter “assumed cause of death”. However it appears logical that all late deaths after ICU discharge were due to a potentially occult complication.

Surprisingly, we found relevant differences between trauma centers of different care levels. About 5% of our study population was treated in a local level 3 trauma center, 24% in a regional level 2 trauma center, and the vast majority in a supra-regional or level 1 trauma center. The percentage of non-survivors after initial ICU discharge was highest in level 3 centers and lowest in level 1 centers (Table 2). Although it seems intuitive that fewer late fatal complications occur in experienced trauma centers, previous studies focusing on the relationship between center volume and complication rates were inconclusive. Several studies found a correlation between high volume and improved outcome, especially in high-risk surgical and trauma patients [31‐33] However, other studies found no association between institution or surgeon volume and survival [34‐36]. Bell et al. [37] investigated the relationship between trauma center volume and in-hospital outcome and showed that higher hospital volumes were associated with decreased likelihood of mortality but not for complication or FTR.

We cannot conclude from our data that our findings were related to differences in availability of ICU beds, other recourses or higher rates of failure to rescue (FTR). Different institutions may have different limitations in resources and, for example, comfort care in the high-dependency unit in one hospital may be equivalent to staying in the ICU for comfort care in another hospital.

Although our study identified a cohort of FTR patients, we could not measure and compare FTR rates. Firstly, we did not know whether patients that died during their initial stay in the ICU suffered from complications or what the influence on mortality might have been. Secondly, we did not know complication rates of surviving patients to show the rate of survived complications.

FTR rates are considered as a quality indicator superior to complication or mortality rates as they are more associated with institutional factors [38‐41]. The rate was based on elective surgical populations and reclassified deaths not caused by adverse events. Holena et al. [38] demonstrated that this approach lacks validity in trauma because patients often die as a direct consequence of injury without any adverse events. They also argued that another common approach to simply exclude deaths without recorded adverse events reduces the reliability of the FTR rate. They proposed to include all deaths but excluding those with an expected mortality > 50%. Though the limit is still under discussion and yet to set definitely.

Moore et al. [39] performed a systematic review on complication rates as a trauma care performance indicator. Only three complications (pneumonia, pulmonary embolism and deep vein thrombosis) were recommended to evaluate acute trauma care hospitals. A recent study by Chung et al. [40] showed that 33% of all major complications in trauma patients occurred on normal surgical wards.

Rauf et al. [42] observed that the time distribution of in-hospital mortality in severely injured patients shows a constant decrease. About 61% of all deaths occur within the first 48 h after admission. Mean time to death was about 6.5 days with a median of 2 days.

This might suggest to focus on the initial hours and days after trauma in terms of quality improvement. However, we believe that our study identified a relevant field of potential improvement to decrease mortality rates even further.

Therefore we propose the mortality rate of patients after initial discharge from ICU as a reliable quality indicator for trauma care. Its calculation and extraction from registries is simple and independent from definition and measurement of adverse events.

17.7% of all non-surviving patients after severe injury initially treated on an ICU, have been discharged to the general ward prior to their death. These deaths can only partially be explained by a limitation of life-sustaining therapy due to a living will. They might represent an important group of patients that might have died from potentially avoidable and treatable complications. The incidence of mortality after discharge from the ICU might be a valuable quality indicator for trauma care of the severely injured patients provided that patients undergoing palliative care are excluded reliably. Further studies are required to identify patients at risk of dying after discharge from the ICU at an early stage and characteristics responsible for the adverse outcome.