Severe Acute Injury Morbidity: A Study to Define Injury Near-Miss
Lateef Thanni and Sunday Sofola-Orukotan
World Journal of Trauma and Critical Care Medicine 2015, 3:1
Critical incident audit of trauma care is traditionally performed by mortality audits which is inadequate to describe morbidity associated with injuries. The injury severity scores available are used to predict death as an outcome of treatment but are also unable to predict morbidity as a tool to improve care and aid policy making. There is still a need for a clinical injury assessment tool that can assess morbidity (by introducing the concept of severe acute injury morbidity or near-miss injury morbidity) and quality of trauma care in relation to available facilities.
Aims and objectives
This study was intended to confirm the relevance of the concept of severe acute injury morbidity (SAIM), describe the characteristics of patients with SAIM and describe the epidemiology of their injuries. It is hypothesized that SAIM will outnumber injury mortality.
This is a prospective descriptive study of a cohort of injured patients who develop acute complications that threaten life without resulting in death. No patient intervention was involved. Eligible patients were injured patients who develop organ system failure or management failure. Patients that were brought in dead were excluded.
There were 118 severely injured patients out of a total of 1885 injured, with a M:F ratio of 3.4:1 and mean age 37.5 years. The mean injury-arrival interval was 3.2 hours. Only 32 patients (27.1%) received preadmission care of which only one was on-board an ambulance. The etiology of injury were road traffic crash (RTC) 86.4% and firearm injury 5.9% while specific trauma diagnoses were traumatic brain injury (TBI) 35.6% and fractures 26.3%. The mean systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate (RR) and heart rate (HR) were similar for patients that died and those with SAIM. HR range however were unrecordable – 140 beats/min and 24 – 128 beats/min respectively. A total of 141 SAIM markers were identified in the 118 severely injured patients. Eighty-nine occurred in the SAIM cases while 52 occurred in those that died (Chi square = 0.72, p = 0.4). The SAIM initiating factors were hypovolaemia 52.5%, TBI 25.4% and sepsis 1.7%. The incidence of mortality and severe acute injury morbidity (near-miss injury) were 2.1% and 4.1% of all injured patients respectively while SAIM index was 339 per 1000 severely injured. The mortality indexes for near-miss initiating factors were 47% for TBI, 42.9% for respiratory distress, 30% for hypovolaemia and 12% for life saving surgery.
Severe acute injury morbidity occurs twice as often as trauma deaths. Trauma deaths may be associated with heart rate <25 or >128 beats per minute, injury-arrival interval greater than an hour and the presence of multiple near-miss injury markers. The most important near-miss injury initiating factors are TBI, respiratory distress and hypovolaemia. Cases of SAIM outnumbers trauma deaths by two to one
severe acute injury morbidity; near-miss injury morbidity; mortality index; trauma; injury; near-miss injury marker; quality of care; initiating factors