Introduction: This study aimed to conduct detailed reviews of prehospital and early in-hospital trauma deaths to identify opportunities to improve the system of care.
Methods: We performed a retrospective review of prehospital and early in-hospital (<24 hours) trauma deaths following a traumatic out-of-hospital cardiac arrest (OHCA) that were attended by Ambulance Victoria (AV) between 2008 and 2014. Data from the Victorian Ambulance Cardiac Arrest Registry (VACAR) were linked with coronial data from the National Coronial Information System and, for patients transported to hospital, to the Victorian State Trauma Registry.
Using a multidisciplinary expert panel review methodology, a detailed review of each case was conducted to evaluate whether a proportion of these deaths were potentially preventable or preventable and to identify opportunities for improvement in the system of care provided to trauma patients.
Results: Over the study period, there were 2,759 trauma-related deaths attended by AV. Of the 777 patients that received attempted resuscitation, 113 cases had full autopsies and were deemed to have ‘survivable’ anatomical injuries. Of these, there were 90 (80%) deaths that were considered to be non-preventable, 19 (17%) that were considered to be potentially preventable and 4 (3%) preventable deaths. Potentially preventable or preventable deaths represented 7% of cases that had attempted resuscitation from paramedics.
Conclusions: No systematic problems were identified. Rather, we identified a number of specific circumstances in which the system of care provided to the patient was suboptimal. The identification of these issues highlights opportunities to make incremental improvements to reduce trauma mortality.