This is the first in a series of four posts on mortality in trauma performance improvement.
The American College of Surgeons has a very specific naming convention for trauma deaths. This is an update of the system used prior to the current Optimal Resource Document (Orange Book), and has actually been revised since it was published. 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
Newest nomenclature: Mortality without opportunity for improvement (mortality w/o OFI)
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 mortality w/o OFI. First, if your center is providing great care, the majority of your deaths (about 90%) 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. Low volume centers may find value in reviewing these cases just to keep up on the detailed analysis and discussion required.
And how do you decide that there is no opportunity for improvement? The key is to look at the true clinical patient impact of the issue identified. If the issue is a minor clerical issue that has little impact on patient outcome or care, it can be classified as being without OFI. But it still needs to be reviewed, closed, and documented. If, however, future patients would benefit from having it closed, you must bump it up to the next category, mortality with opportunity for improvement.
In my next post, I’ll discuss the next type of trauma mortality, mortality with opportunity for improvement. I’ll follow up with the dreaded unanticipated mortality, and end with a bonus post on some nuances to that classification.