Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

The problems of estimating the quality of medical assistance for patients with polytrauma have both medical and socioeconomic significance [1-5, 7, 9, 10-13, 24].

As a rule, investigation of quality of medical assistance is based on the analysis of hospital mortality and the level of clinical diagnostics of the main criteria, which allow visual demonstration of defects in diagnostics, treatment and organizing medical assistance. 

As the authors indicate, estimation of mortality after polytrauma often requires detalization and explanation. According to the multiple literature sources, the mortality varies within 15.9-49.5 %. Some publications demonstrate higher percentage. But often they do not consider the characteristics of dominating injuries, admission time, volume and quality of assistance, developed complications and others [16, 17, 23, 26, 27].

The issues about expert estimation of patients with polytrauma, financial provision for medical process, consideration of incidence, analysis of results of activity of medical facilities and other factors are considered on the basis of International Classification of Diseases (ICD). At the present time ICD of 10^th revision is used [20]. ICD codes are nominal. It means that they present non-ordered, qualitative categories, which are classified for estimation of location of specific injuries. The principle of classifying patients according to main diagnosis, which is coded in concordance with ICD-10, or according to the main surgical intervention, did not allow adequate classification of patients with severe multiple or concomitant injuries. This position has changed itself after implementation of clinical statistical groups (CSG), which gave the possibility for separation of clinically homogenous groups of patients who received medical assistance in association with almost equal severity of injuries. Undoubtedly, patients with polytrauma present such group. It is supported by the experience from other countries using CDG for objective estimation of this category of patients, and for estimation of payment for realized hospital management: severe multiple injuries are separated into the individual category.        

During the discussion of directions for improvement of CDG the decision was made about inclusion of polytrauma into the individual group (the information letter from Ministry of Health of Russian Federation, November, 11, 2013, # 66-0/10/2-8405). On the basis of analysis of the foreign experience polytrauma was offered to be coded with several ICD-10 codes designating severe trauma in several anatomic regions (for example, one code for head and neck region + one code for abdominal injury etc.). The issue about consideration of severity of patients’ state was unsolved and was proposed for consideration. Absence of the uniform federal scale for estimation of severity of injuries and state of patients do not allow using any assessing scale as the basis for classification of patients into CDG. Our offer for salvation of the issue is based on combination of two assessing systems: combination of most common injuries into the groups according to location of injuries, and use of necessary amount of ICD codes, particularly, degree of multiple organ dysfunction; these codes indicate the real situation relating to the patient. Our offer is still being discussed [8, 9].    

Such situation is associated with absence of generally accepted definitions: definition of polytrauma, absence of uniform classification, of generally accepted criteria for estimating injury and patient’s state severity, and developing complications. According to the opinion by most researchers and our opinion, the efforts should be directed to not to creation of new classifications, definitions and estimating scales, but to further development and implementation of existing ones [8, 9, 11, 14, 15, 22, 31].   

The available literature includes more than 20 definitions of polytrauma. Among the most common definitions one can emphasize the recommendations by the domestic authors: Agadzhanyan V.V. et al. (2003), Sokolov V.A. (2006), Gumanenko E.K. (2008) and European Society of Traumatologists (AO Principles of fracture management, 2000).  

They describe the essence of occurring processes with sufficient accurateness, but, unfortunately, it does not permit evaluation of severity of injury and state. Absence of the uniform classification, of general criteria for evaluating severity of state and injuries in patients with polytrauma often results in domination of subjective estimates of severity of state and injuries which can be adequate only in rare cases. Therefore, we use the definition by Agadzhanyan V.V. et al. (2003) as the basis. Polytrauma is the aggregate of two or more injuries, one of which or their combination cause direct threat to the patient’s life and present the immediate cause of traumatic disease development. We considered the amendment from the European international conference: the sum severity of injuries achieves 17 points and more according to ISS. This is the most severe group of patients with heterogeneous injuries with extreme severity of state as result of the injury.             

Objective – to estimate the level and significance of the main factors influencing on the structure of hospital mortality after polytrauma.

 

MATERIALS AND METHODS

The retrospective analysis included 1,303 case histories of the patients with polytrauma who were treated in the specialized traumatology center in Clinical Center of Miners’ Health Protection during 2005-2014. 817 patients were transported by the employees of emergency aid within an hour after injury. 486 patients were transported from the non-specialized medical facilities of Kemerovo region and the neighboring regions (Altay region, Novosibirsk and Krasnoyarsk regions) within 1-7 days. Severity of traumatic injuries was estimated according to ISS (Injury Severity Score), with the mean values of 32.6 ± 0.3 [8, 28, 29].     

The mean age of the patients was 35.6 ± 0.6 (17-76). The men accounted for the largest proportion – 968 (74.6 %), with 329 (25.4 %) women.

229 patients died. The mortality was 17.5 %. All deceased patients were distributed into the groups according age, gender, location of the main (dominating) injury, the main causes and time of death.  

The clinical structural analysis of hospital mortality was made, and the quality of clinical diagnostics was evaluated. The analysis of the causes of death after polytrauma was performed according to the data of forensic expertise with the projects for postmortem clinical diagnosis by Avtandilov G.G. et al. [2], and the regulations and the recommendations from the International classification of diseases (ICD), 10^th revision [20]. During investigation of the forensic conclusions about death the experts established the frequency and characteristics of clinically non-diagnosed injuries and complications, made their systematization, estimated the causes and thanatological significance.

For identification of the structure of defects in diagnostics we used the structural standards for quality of clinical diagnostics [19];

-          Discrepancy between clinical and forensic diagnosis;

-          One (or more) concomitant injuries unrecognized;

-          An unrecognized lethal complication;

-          Late diagnosis of the main disease;

-          Late diagnosis of a lethal complication;

-          Unrecognized concurrent injuries.

 

The causes of the errors were distributed to:

1.      Objective causes (short period of hospital stay, severity of patient’s state);

2.      Subjective causes (insufficient examination, underestimation of anamnesis data, underestimation or incorrect description of clinical data, underestimation or overestimation of laboratory data).

 

The statistical analysis was realized with Statistica 6.1 software.

The comparison of the analyzed values was carried out with the parametric method. Student’s test was used for testing the statistical significance between the groups.   

Pearson’s test was used for estimation of statistical significance during comparison of the data. The linear correlation ratio was used for estimation of the correlation between the signs. The critical level of significance of the null-hypothesis was 0.05.

 

RESULTS AND DISCUSSION

In 80.3 % of the cases the injuries were associated with road traffic accidents, in 10.9 % – with falling from height, in 3.9 % – with industrial accidents, in 4.9 % – with other factors.    

The retrospective analysis of 1,303 case histories of the patients with polytrauma showed significant variations in the number of the patients and in the level of lethal outcomes (table 1).

Table 1
The dynamics in mortality among patients with polytrauma for 2005-2014

These changes were associated with both organized rebuilding of medical assistance for patients with polytrauma and implementation of new technologies into the practical activity in the specialized center. In 2004-2009 the regional program Polytrauma had been implemented, the volume of services had been enlarged, and also implementation included the system for interhospital transportation from non-specialized medical preventive facilities of the region and the neighboring regions under control of the specialized medical team. The modern technologies in the programs for emergent intensive care and surgical interventions have been implemented, the principled approaches to the word combination “a non-transportable patient” and “unsurvivable injury” have been changed. All that significantly influenced on the total level of lethal outcomes after polytrauma. These measures have reduced the regional rate of lethal outcomes from 32 to 21 %; in our center this rate was 10.9-17.5 %. In 2010 the program was reduced, and the number of patients decreased in our center.

Men prevailed among the patients with polytrauma. There were 941 men (72.2 %) and 362 women (27.7 %), as for deceased persons – 169 (73.7 %) and 60 (26.3 %) correspondingly. The hospital mortality in men was 17.9 %, in women – 16.5 %. The differences were statistically significant (p < 0.05) (table 2).

Table 2
Distribution of patients according to age, gender and hospital mortality

Note: * p < 0.05 - level of significance of measurement in comparison of mortality level according to gender .

The patients were of employable age: 88.2 % of the patients were at the age under 60, with the mean age of 43 ± 4.2. Actually the deceased patients with polytrauma were related to young, employable age. This fact supports the multiple literature data about the social significance of polytrauma. The mortality rate increased with age [18, 25]. The maximal mortality (40.9 %) was observed in the age group older 65.

The clear pattern was found that depended on time of transition of the patients to Clinical Center of Miners’ Health Protection and the mortality rate: the later transition was realized, the higher mortality was observed (table 3). In case of transition of patients within the first day the hospital mortality was 6.4 %.

Table 3

Dependence of mortality on time of transfer from other medical facilities

In case of later transfer the mortality rate increased progressively, with the maximal level on day 4 (30 %). On day 5, as a rule, transfer for the patients in compensated state was realized. It conditioned the lower mortality in such patients. The insignificant amount of the transferred patients (66 persons) in this group is conditioned by the fact that most patients were dead at that time, because the mortality achieved 60 % in the non-specialized facilities, and the survived patients had different complications of traumatic disease (pneumonia, ARDS, acute multiple organ dysfunction, sepsis, purulent wounds etc.).

For estimation of relationship between time of transportation and hospital mortality rate in the transferred patients with polytrauma the correlation analysis and estimation of Pearson’s correlation were used. The strong linear relation between time of transfer (days 1-4) and mortality (r = 0.95, p = 0.046).            

As for the rate of identified dominating injuries the patients were distributed as indicated below: skeletal injury (33.1 %), traumatic brain injury (27 %), thoracic injury (17.5 %), abdominal injury (10.3 %), spine and spinal cord injury (6.1 %), concurrent injuries (6 %) (table 4).

Table 4
Distribution of patients with polytrauma and structural characteristics of died patients in relation to a dominating injury

Concurrent injuries were interpreted by us as the situation when one could designate any injury as dominating one, and all of them were life-threatening. Despite of the lowest amount of the patients with concurrent injuries they indicated the highest mortality (72 %). The frequency of lethal outcomes in patients with dominating injuries to central nervous system was 17.6 %, spinal cord – 27.8 %, dominating thoracic injury – 16.6 %, abdominal injury – 16.7 %. The lowest frequency of lethal outcomes was observed in dominating skeletal injury (6.5 %). We should note that thoracic and traumatic brain injuries were identified in 73.4 % of the lethal cases, but were not dominating injuries. These injuries contributed to the rate of purulent septic complications in early period of polytrauma that increased severity of state and frequency of lethal outcomes.        

It was very notable with the analysis of the group of the patients with concurrent dominating injuries. In 56 patients (24 %) in 72.3 % of the cases we noted the combinations of thoracic injury with another dominating injury (table 5).   

Table 5
Mortality structure in patients with concurent dominating injuries

This category of patients demonstrate the following patterns: 70.4 % – combinations of injuries in 3 or more anatomic regions, 77.5 % – shock of degree III (usually hemorrhagic one), multiple organ dysfunction. As for the patients with concurrent dominating injuries, the highest mortality was associated with combination of thoracic and traumatic brain injuries (42.9 %). The combination of traumatic brain and abdominal injury was identified in 21.5 % of lethal outcomes. In the group of the patients with concurrent dominating injuries the absence of traumatic brain or thoracic injury resulted in four-five-fold decrease in risk of unfavorable outcomes.

For the mortality analysis in concordance with hospital stay the patients were distributed into 3 groups with approximate compliance with acute (days 1-3), early (days 4-10) and late (> 10 days) periods of traumatic disease (table 6).

Table 6
Mortality structure in dependence on duration of hospital stay

49 patients died within 3 days (21.4 % of total number of deaths after polytrauma). Herewith, 24 hour mortality was 10.1 % (23 patients). 64 patients (27.9 %) died on days 4-10. 116 patients died in late period of traumatic disease (50.6 % of lethal outcomes after polytrauma).

Such distribution (depending of time of hospital stay) of deceased patients with polytrauma generally corresponds to the literature data indicating mortality of 60-70 % in acute and early periods, and 30-40 % in the period of late manifestations of traumatic disease [16, 25, 26].

According to our data, during the last years one can observe the obvious tendency to reducing rate of lethal outcomes in early and acute periods of traumatic disease and increase in late period (days 10-28). Decrease in mortality within days 1-3 was achieved as result of development and implementation of the big set of organizational and medical diagnostic programs, improvement in medical diagnostic measures during transportation, reducing time of presurgical examination with  high informative techniques (ultrasound, MSCT, laparoscopy etc.), active implementation of modern high tech methods for intensive care (infusion-transfusion, vascular and respiratory support). The great significance is related to implementation and readiness to day and night mode of replacement therapy techniques (ALV, autoblood reinfusion with cell-celver device, dialysis methods etc.) [3, 4, 5, 6, 21].

All positive moments of damage control system were used owing to objectification of state in patients with polytrauma and decision about degree of its compensation, permissibility of aggressive methods of treatment on the basis of the generally accepted international scale for estimating severity of state in polytrauma, severity of traumatic injuries and degree of organ dysfunction in our modification [7, 9, 10, 22, 31, 32].

The modern systemic approach to treatment of patients allows realization of specialized medical assistance in acute and early periods of polytrauma. Herewith, one could observe increase in the amount of “resuscitation long-livers”, and the priority is given to realization of specialized assistance for developing complications, purulent septic complications, multiple organ insufficiency etc. [3, 4, 5, 6, 29, 30].    

According to results of the forensic examination the leading causes of lethal outcomes in acute period of traumatic disease were acute blood loss and shock as result of extremely severe injury to parenchymal organs, the brain [32], cerebral edema with stem dislocation [21], ascendant edema of the spinal cord, heart contusion [2].

In early period of traumatic disease the mortality rates are still without tendency to significant decrease. The immediate causes of death in early period of traumatic diseases were severe reperfusion complications with development of different forms of organ insufficiency, infection complications: multiple organ insufficiency, ARDS III-IV – pneumonia, cerebral edema with stem dislocation, peritonitis, sepsis, ascendant edema in the spinal cord [2, 21, 32] (table 7).

The thanatological profile (the structure of direct causes of death) in the studied period was as indicated in the table 7. As for acute period, these are shock and blood loss – 31 (13.5 %), edema and dislocation of the brain – 41 (17.9 %); in early period: MODS – 86 (37.5 %), infectious diseases – 66 (28.9 %), others – 5 (2.1 %).

Table 7
The causes of lethal outcomes in different periods of traumatic disease

There were no discrepancies relating to the main disease during comparison of postmortem clinical and forensic diagnoses. The greatest amount of diagnostic errors (80.2 %) was noted in acute period of traumatic disease. As a rule, they were conditioned by the objective causes: extremely severe state of patients at moment of admission, necessity of emergent and sometimes simultaneous conduction of resuscitation and surgical procedures, short stay in the hospital [18].

As for sections, the first place was taken by rib fractures: they were found in 21 postmortem examinations (23 %), when the number of fractured ribs was higher in comparison with data of intravital diagnostics (X-ray examination). The second place was taken by fractures of the facial bones: nose, eye pit, lower jawbone in 20 cases (22 %). More rarely the fractures of spinous processes and isolated fractures of pubic and ischial bones were identified. In most cases such fractures were not visible in the plain anterioposterior X-ray images. There were no fatal non-diagnosed injuries to the internal organs. In 10 cases (11 %) autopsy found subcapsular ruptures and hemorrhages to the spleen and the liver. Also small (about 20 ml) intracranial lamellar hematomas were identified.                                   

The identified defects in diagnostics had no significant influence on dynamics of traumatic disease ant lethal outcomes. The causes of defects were associated with insufficient experience in most cases. 

Prevention of such situations is associated with adherence to the protocol of diagnostic algorithm in polytrauma: obligatory realization of all available diagnostic methods and participation of specialists with specific skills. A specialized trauma center provides such opportunities on a 24-hour basis.

 

CONCLUSION

The main directions for decreasing mortality in patients with polytrauma can be divided into organizational, diagnostic and curative.

All patients with polytrauma should receive treatment in specialized trauma centers with modern material and technical basis and qualified specialists for realization of medical diagnostic process.

The optimal time for transfer of patients with polytrauma to a specialized trauma center is 24 hour period after trauma. In later transfer the predicted outcome worsens significantly, and mortality increases (23.6 % increase for transfer on day 4). Interhospital transfer (to a specialized trauma center) for patients with concurrent dominating injuries and dominating traumatic brain injury should be realized only after appropriate preparation, compensation or, at the very outside, after subcompensation of patients’ state.

It is necessary to realize further discussion and acceptance of the uniform classification of polytrauma for Russian Federation (ideally, the international standard), the available dynamic scale for severity of state which allows making decisions about complex issues of medical tactics.

The highest hospital mortality is observed in patients with concurrent dominating injuries (72 %). The second place is related to patients with dominating spine-spinal cord injury, with mortality of 27.8 %. These are patients with extremely severe injuries at the cervical level, with ascendant spinal cord edema as the main cause of lethal outcomes. As a rule, spine and spinal cord injury is combined with thoracic injury that is one of the most unfavorable predictive factors. Almost identical level of mortality is observed in the patients with dominating traumatic brain, abdominal and thoracic injuries (16.6-17.7 %). But if in the group of patients with dominating abdominal injury the high mortality is conditioned by late transfer and, as result, by severe purulent complications (peritonitis, sepsis), in the group of patients with dominating traumatic brain injury the mortality rate, besides of transfer time, is influenced by degree of cerebral injury (edema and crushing of the brain, impaction of stem structures). ARDS of degrees 3-4 and pneumonia are the main causes of lethal outcomes in dominating thoracic injury. The group of patients with dominating skeletal injury demonstrates the most favorable results. In case of adequate treatment the mortality is 6.5 %. The main causes of death were massive blood loss and shock.

It is necessary to note that in early and late periods of traumatic disease the direct causes of death (in most cases) were infectious complications of traumatic disease at the background of secondary immunodeficiency and MODS. Keeping in mind the existing structure of the hospital mortality it is necessary to give special attention to prevention and treatment of early and late complications of polytrauma.