Effect of a Voluntary Trauma System on Preventable Death and Inappropriate Care in a Rural State

Abstract

This study compares the preventable death rate and the nature and degree of inappropriate care in a rural state before and after implementation of a voluntary trauma system. Deaths attributed to mechanical trauma occurring in the state of Montana between January 1, 1998, and December 31, 1998, were retrospectively reviewed by a multidisciplinary panel of physicians and nonphysicians representing the hospital and prehospital phases of care. Deaths were judged frankly preventable, possibly preventable, and nonpreventable. Care rendered in all categories was evaluated for appropriateness according to nationally accepted guidelines. Results were then compared with an identical study conducted before implementation of a voluntary trauma system. Measures to ensure comparability of the two studies were taken. Three hundred forty-seven (49%) of all trauma-related deaths met review criteria. The overall preventable death rate (PDR) was 8%. In those patients surviving to be treated at a hospital, the PDR was 15%. The overall rate of inappropriate care was 36%, 22% prehospital and 54% in-hospital. The majority of inappropriate care in all phases of care revolved around airway and chest injury management. The emergency department (ED) was the phase of care in which the majority of deficiencies were noted. In comparison with the results of the earlier study, PDR decreased (8% vs. 13%, p < 0.02). Adjusted rates of inappropriate care also showed a decrease (prehospital, 22% vs. 37%; ED, 40% vs. 68%; post-ED, 29% vs. 49%); however, the nature of deficiencies was the same. Population characteristics influencing interpanel reliability were similar for the two groups compared. Agreement on test cases presented to both panels was good (kappa statistic, 0.8). Implementation of a voluntary trauma system has positive effects on PDR and inappropriate care. The degree and nature of inappropriate care remain a concern. Mandated and funded system policies may further influence care positively.