Anesthesia
Trauma Systems
Burn injury acute care
Over the past half-century, major improvements have occurred in the treatment of burn patients. At the end of World War II, for example, less than half of patients survived burns involving 40% of their total body-surface area. By the late 1990s, over half of all patients survived with burns involving 80% of their total body-surface area. This remarkable success can be attributed to various therapeutic developments, including vigorous fluid resuscitation, early excision of burn wounds, advances in critical care and nutrition, prompt treatment of infection with powerful antibiotics, and the evolution of specialized burn centers.
Today, few children with burn injury less than 60% of their body surface cannot be saved and many with more massive burns can survive. Fortunately, while some children surviving very severe burns have lingering physical disability, most have a satisfying quality of life.
Moral: Improving trauma care reduces injury fatality rates.
Sources:
Wolf SE, Rose JK, Desai MH, Mileski JP, Barrow RE, Herndon D. Mortality determinants in massive pediatric burns. Annals of Surgery. 1997; 225:554-569
Saffle JR. Predicting outcomes of burns. New England Journal of Medicine. 1998; 338:387-388.
Sheridan RL, Hinson MI, Liang MH, Nackel AF, Schoenfeld DA, Ryan CM, Mulligan JL. Long term outcome of children surviving massive burns. JAMA. 2000; 283:69-73.
O'Neill JA Jr. Advances in the management of pediatric trauma. American Journal of Surgery. 2000; 180:365-369.
In the late 1970s and early 1980s, record number of patients began to sue anesthesiologists for malpractice; malpractice premiums for anesthesiologists skyrocketed, becoming the most expensive in medicine. In 1982, the ABC newsmagazine 20/20 aired a segment highlighting shoddy anesthesia practices at several institutions.
In the mid-1980s, the major malpractice carrier for the nine Boston hospitals affiliated with Harvard Medical School helped spur Harvard physicians to create the first set of comprehensive practice standards for the field; these quickly gained broad currency. Standardization of existing equipment, better training (e.g. simulators) and new monitoring technology (e.g. pulse oximetry, which uses a small clip on the patients fingertip to measure oxygen in the blood, and capnography, a companion device, which measures carbon dioxide in the blood) were key in helping to reduce mistakes. The visible commitment of the professional society to rapid and continued reduction in physician error appears to have been crucial for success.
It is estimated that patient death rates have declined from two per 10,000 anesthetics administered in the early 1980s, to one in 200,000 by the late 1990s. Whereas anesthesiologists paid about $30,000 per year for malpractice insurance in the early 1980s, that rate fell to about $5,000 to 10,000.
Moral: Tort law sometimes provides financial incentives to effectively reduce injury.
Sources:
Institute of Medicine. To Err is Human: Building a Safer Health System. Washington D.C.: National Academy Press, 2000
Ziegler J. A medical specialty blazes a trail. Accelerating Change Today for America's Health. February, 2000. pp 26-28.
Cooper JB. Accidents and mishaps in anesthesia: how they occur; how to prevent them. Minerva Anestesiologica. 2001; 67:310-313.
Trauma Systems
Creation of trauma systems helps ensure that patients are treated in the most appropriate facilities. Studies of trauma systems indicate that they reduce mortality by 15-20% for very seriously injured patients who are treated at trauma centers versus non-trauma centers.
For example, a before-after study of a trauma system in San Diego County found that, before regionalization, 32% of major trauma victims received sub-optimal care, compared to 4% after regionalization. Preventable deaths occurred in 14% of fatalities before the implementation of the trauma system, compared to 3% after implementation.
Moral: Good medical care helps prevent injury mortality
Sources:
Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published evidence regarding trauma system effectiveness. Journal of Trauma. 1999; 47(3 Suppl):S:25-33.
Shackford SR, Hollingworth-Fridlund P, Cooper GF, Eastman AB. The effect of regionalization upon the quality of trauma care as assessed by concurrent audit before and after institution of a trauma system: a preliminary report. Journal of Trauma. 1986; 26:812-820.
Trauma Systems Bibliography http://www.nscot.org/literature.htm