Yesterday I tried to clarify the most commonly assigned type of trauma mortality, anticipated mortality without opportunity for improvement (AMW/OOI). Today, I’ll cover another, and I’ll finish the series on Monday.
Old nomenclature: potentially preventable death New nomenclature: anticipated mortality with opportunity for improvement (AMWOI)
Again, these sound somewhat similar but they are quite different. Potentially preventable death used to be applied to patients who had obvious care issues that had some potential to change outcome. But it also contained a number of patients discussed yesterday who had support withdrawn due to age or degree of injury. There was some nagging doubt that, it something else had been done, maybe they would have recovered. So several of the “potentially preventable” deaths in the old category have been moved to the “without opportunity for improvement” category.
Unfortunately, a larger group of patients from the nonpreventable death category have moved into the “with opportunity for improvement” category. This is actually a good thing, though. The AMWOI category looks at whether there were any care issues, regardless of whether support was eventually withdrawn.
Whereas the vast majority of deaths at any center should fall into the AMW/OOI category, a modest number will be classified as AMWOI. The actual number depends on how broadly or narrowly an opportunity for improvement is defined. If you consider a few areas of missing documentation on the trauma flow sheet an opportunity for improvement, then you’ll have a lot of deaths classified this way. Concentrate on issues that might have actually had an impact on the outcome. The key is to develop a set of criteria that is realistic and that work for you. If the number of AMWOI deaths seems high, go back and look at those criteria and adjust them. You can still work out a system for improving trauma flow documentation without it changing every death in a trauma activation to one with an opportunity for improvement.
Monday, I’ll finish up with a few words on unanticipated mortality.
The American College of Surgeons adopted a new naming convention for trauma deaths last year. Of course, anytime you change something up, there will be some confusion. I’m going to compare old and new and give some of my thoughts on the nuances of the changes.
Old nomenclature: Nonpreventable death New nomenclature: Anticipated mortality without opportunity for improvement (AMW/OOI)
They seem similar, right? But the new name takes into account a growing phenomenon: elderly patients (or younger ones for that matter) who sustain injuries that might be survivable, but are devastating enough to cause the family to withdraw support. Technically, the deaths could be preventable to some degree, but the family did not wish to attempt it. The new system recognizes that it is an expected outcome due to patient or family choice.
There are several key points to handling AMW/OOI. First, if your center is providing great care, the majority of your deaths should be classified this way. Every one of them needs some degree of review, whether from just the trauma medical director and/or program manager or via the full trauma PI committee. However, your full PI committee needs to at least see a summary of the death if it’s not discussed in full.
How to decide on abbreviated review and report vs discussion by full committee? It depends on your trauma volume, and program preference. Higher volume centers do not usually have the luxury of discussing every case due to time constraints.
Tomorrow I’ll discuss the next type of trauma mortality, aniticipated mortality with opportunity for improvement, and I’ll finish the series on Monday.
Okay, so you’ve seen “other people” wearing perfectly good lead aprons lifting them up to their chin during portable xrays in the trauma bay. Is that really necessary, or is it just an urban legend?
After hitting the medical radiation physics books (really light reading, I must say), I’ve finally got an answer. Let’s say that the xray is taken in the “usual fashion”:
Tube is approximately 5 feet above the xray plate
Typical chest settings of 85kVp, 2mAs, 3mm Al filtration
Xray plate is 35x43cm
The calculated exposure to the patient is 52 microGrays. Most of the radiation goes through the patient onto the plate. A very small amount reflects off their bones and the table itself. This is the scatter we worry about.
So let’s assume that the closest person to the patient is 3 feet away. Remember that radiation intensity diminishes as the square of the distance. So if the distance doubles, the intensity decreases to one fourth. By calculating the intensity of the small amount of scatter at 3 feet from the patient, we come up with a whopping 0.2 microGrays. Since most people are even further away, the dose is much, much less for them.
Let’s put it perspective now. The background radiation we are exposed to every day (from cosmic rays, brick buildings, etc) amounts to about 2400 microGrays per year. So 0.2 microGrays from chest xray scatter is less than the radiation we are exposed to naturally every hour!
The bottom line: unless you need to work out you shoulders and pecs, don’t bother to lift your lead apron every time the portable xray unit beeps. It’s a waste of time and effort!
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