Discussion
Although many trauma clinicians are aware of processes and outcomes at their respective trauma centers, the ability to evaluate the entire regional trauma system and thus the nation in a comprehensive fashion is lacking. By virtue of their statutory role, medicolegal death investigation agencies are the repository of data on trauma deaths within a geographic area. However, in the USA, these agencies rarely interact with trauma centers or regional/state trauma systems. In contrast, in the UK and New Zealand, the medicolegal death investigation system has established entire departments that exclusively work with clinicians for the sole purpose of identifying, discussing, and addressing P deaths.8 9 19 20 Linking the two systems, clinical trauma care and death investigative services, is crucial to establishing an accurate regional PDR.
In developing this study design, several unique opportunities for improving data gathering within the trauma system were discovered and should be considered for future studies. These challenges include the following: longitudinal perspective of trauma deaths, nontrauma center deaths, deaths with confounding medical factors, readmissions within 30 days, patients who visited multiple hospitals or urgent care or primary care providers for initial points of contact, and linkages between the multiple different data sets. Sharing the outcome of these and similar studies on potential preventability with local, regional, and state officials should aid in improving trauma system outcomes. Figure 3 illustrates the various system gaps that offer opportunities for system improvements within trauma care.
Figure 3System gaps after traumatic injury. EMR, Electronic Medical Record
A longitudinal perspective of trauma deaths (ie, deaths from remotely sustained injuries and often years after the acute event) presents challenges in data collection and abstraction simply because of the often complex course of care that may occur after the initial hospitalization. Although trauma systems address the spectrum of acute patient care (eg, prehospital, hospital and rehabilitation), frequently long-term outcomes of the course of care and patient progression after discharge are not always known. This project is expected to provide data as to decedents who died due to complications from injuries sustained months or years in the past.
While collecting data from non-trauma hospitals and factoring in care from free-standing clinics is a challenge, this evaluation provides an immediate tangible benefit: namely, an evaluation of triage by EMS of trauma patients to non-trauma centers and subsequent decision to transfer to a trauma center. Given the large number of non-trauma centers, numerous urgent care or free-standing clinics, and even primary care physicians identified as the first point of care providing trauma care services, over/under triage is a key indicator of how well a trauma system is working. Expansion of this study will inform EMS of crucial areas for improvement in this regard.
Although 30-day readmissions are tracked at a state level and frequently within healthcare systems as indicators of quality, this information is usually not shared or even linked between hospitals. If a patient is readmitted to a different system either by choice or EMS decision, the initial treating hospital or clinician is often unaware of this potentially missed opportunity for improving care. This project will attempt to place timelines on each death, including readmissions or discharge from a hospital with subsequent death at home. This approach has potential value for improving population-level trauma care by identifying gaps in appropriate post-discharge interpersonal or community-level support for trauma patients.
Unlike previously published studies assessing survivability in military settings with study populations that composed of primarily young, physically fit males who died predominately from explosion or gunshot injuries,10–13 this project addresses a demographically diverse population crossing the lifespan with the multiple underlying natural pathological changes associated with the natural aging process. For example, the data include a large proportion of blunt traumatic brain injury deaths resulting from falls in the elderly population. Geriatric patients who fall multiple times and are cared for at multiple disconnected hospitals before finally succumbing to a fatal fall composed of a unique population at a great risk and potential benefit.
The US Military used a similar scheme to drive improvements in their trauma system during the most recent war. These improvements are largely centered on extremity and truncal hemorrhage control, resuscitation and trauma system implementation. Similar haemorrhage control opportunities exist in the civilian system, but because of different demographics it is likely that data-driven prevention and triage strategies will also greatly improve outcomes in the civilian arena.
Finally, the linkage of data in efforts to improve trauma care is critical.1 This project may demonstrate that those who die from complications of remote trauma or geriatric falls often do not receive their care within one system. Thus, improvements in managing the care of trauma patients throughout the larger regional system, that is, from trauma prevention, EMS transport, acute care and through rehabilitation to death, may be needed.
Future directions
Future directions should address policies to support and encourage linkages of data from law enforcement agencies, primary care providers, prehospital setting, free standing emergency rooms, hospitals, rehabilitation facilities, and medical examiners/coroners. Several system-level quality and safety opportunities may be identified within the actual analysis of the data. Importantly, the availability of real-time reporting of autopsy-determined cause of death in regard to preventability within weekly morbidity and mortality conference can lead to rapid improvements in care. In addition, an economic analysis of the current state of both Harris County and state-level trauma systems should be prioritized. This analysis should include a comparative cost analysis of trauma care provided between trauma and non-trauma centers and the cost to implement the regionalization of medicolegal death investigation systems. The inclusive trauma system should embrace the forensic service, so that prevention, prehospital, acute, rehabilitation, and long-term care can be optimised. Taking the lead from our military colleagues, establishing a reliable civilian trauma PDR and methods that can be replicated across different regions is a growing priority in light of increasing unintentional and intentional trauma-related deaths. Finally, it is only through the analysis of all the data from all the agencies constituting a truly comprehensive trauma system that innovative, data-driven interventions be implemented.