Tag Archives: autopsy

Performance Improvement

Autopsy Reports and Performance Improvement

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Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine opportunities for improvement when reviewing mortality cases where the etiology is not clear. Deaths that occur immediately prior to arrival or in the ED are typically those in which most questions arise.

The American College of Surgeons Trauma Verification Program previously included a question on what percentage of deaths at a trauma center undergo autopsy, but this was discontinued with the 2022 standards. Low rates were usually discussed further, and strategies for improving them were considered. But even though autopsy review rates are no longer scrutinized, are they really that helpful?

A total of 434 trauma fatalities in one state over a one year period were reviewed by a multidisciplinary committee and preventability of death was determined. Changes in preventability and diagnosis were noted after autopsy results were available.

Here are the factoids:

  • The autopsy rate was 83% for prehospital deaths and 37% for in-hospital deaths
  • Only 69% were complete autopsies; the remainder were limited internal or external only exams
  • Addition of autopsy information changed the preventability determination in 2 prehospital deaths and 1 in-hospital death (1%)
  • In contrast to this number, it changed the cause of death in about 40% of cases, mostly in the prehospital deaths

Bottom line: From a purely numerical performance improvement standpoint, autopsy did not appear to add much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. And it may modify some of the diagnoses recorded in the trauma registry.

Anecdotally, I have received reports that opened my eyes to significant opportunities for improvement. I would still recommend obtaining the reports and performing at least a cursory review for their educational value, especially for those of you who are part of residency training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. J Trauma 73(3): 587-590, 2012.

Abstracts, Imaging

Best Of EAST 2023 #7: The CT Autopsy

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Back in the day, autopsy after trauma death was fairly commonplace. Nowadays, it is typically reserved for fatalities that involve a potential crime. And it can be challenging to get the medical examiner to release copies for trauma performance improvement.

One potential remedy for this began to surface in the literature about twenty years ago: the virtual (or CT) autopsy. This entails sending the postmortem patient to the scanner for head, cervical, chest, and pelvic scans. Although it seems like an exciting idea, there are several logistical issues that I will discuss later.

The trauma group at Indiana University performed a retrospective study to determine the common injury patterns in patients who died at or up to one hour after ED arrival. Their goal was to identify injury patterns that might improve the focus and quality of resuscitative efforts in living patients. They reviewed their experience with doing postmortem CT over a nine-year period. The primary goal was to identify sources of hemorrhage, TBI, and cervical spine injury. They also wanted to identify significant pneumothorax and misplaced airway devices.

Here are the factoids:

  • There were 80 decedents in the study, and they were severely injured, with an average ISS of 42
  • About three quarters arrested prior to arrival, and the remainder arrived with a pulse
  • The most common major injuries were severe TBI (41%), long bone fractures (25%), hemoperitoneum (23%), and cervical spine injury (19%)
  • A moderate pneumothorax was present in 19% of cases
  • Misplaced airway was identified in 5%
  • There was no difference in injury or device mishap patterns between pre-hospital and in-hospital arrest patients (although the number of patients was probably too small to detect one)

The authors concluded that the injury patterns between those who died prior to arrival vs. after were the same. They also noted that patients in arrest should automatically have their chest decompressed and the airway position checked.

Bottom line: This is an intriguing study of a concept I’ve been thinking about for years. The quality improvement benefits could be amazing! Imagine getting immediate feedback on the cause of death and how it might influence future resuscitations. The authors pointed out the power of this with their discovery of missed pneumothorax and malpositioned airways.

But, as mentioned above, there are a host of logistical problems to work out first. Here is a partial list:

  • Who accompanies the patient to scan? A nurse? The team?
  • Covered or uncovered? It might be creepy for people in the hallways to see a covered person being wheeled around. That’s why hospitals always have those white, wheeled boxes. But it’s equally creepy to see a person who is not moving or breathing being transported.
  • Be prepared for your radiologists to gripe about doing free reads
  • Where does the report go? It shouldn’t go to the medical record. Or should it?
  • What about liability issues? If the team misses something big and the report goes to the chart, it’s fair game for a lawsuit.
  • And many more!

Here are my questions and comments for the presenter/authors:

  • How did you come to do this study? It appears that your group has been performing CT autopsies for almost a decade. Was there a protocol? Was it done on every eligible patient? If not, could this have skewed your results?
  • Do you have the statistical power to detect any differences between the various groups? A few of your results did approach significance. Perhaps more subjects would have helped.
  • Tell us how you have addressed the logistical problems above.

This is great work; perhaps it will stimulate a move toward embracing this concept!

Reference: CHARACTERIZATION OF FATAL BLUNT INJURIES USING POST-MORTEM COMPUTED TOMOGRAPHY. EAST 2023 Podium paper #14.

 

General

Autopsy Reports and Performance Improvement

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Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine preventability of death in cases where the etiology is not clear. Deaths that occur immediately prior to arrival or in the ED are typically those in which most questions arise.

The American College of Surgeons Trauma Verification Program includes a question on what percentage of deaths at a trauma center undergo autopsy. Low numbers are usually discussed further, and strategies for improving them are considered. But are autopsies really that helpful?

A total of 434 trauma fatalities in one state over a one year period were reviewed by a multidisciplinary committee and preventability of death was determined. Changes in preventability and diagnosis were noted after autopsy results were available. 

Here are the factoids:

  • The autopsy rate was 83% for prehospital deaths and 37% for in-hospital deaths 
  • Only 69% were complete autopsies; the remainder were limited internal or external only exams
  • Addition of autopsy information changed the preventability determination in 2 prehospital deaths and 1 in-hospital death (1%)
  • In contrast to this number, it changed the cause of death in about 40% of cases, mostly in the prehospital deaths

Bottom line: From a purely performance improvement standpoint, autopsy does not appear to add much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. And it may modify some of the diagnoses recorded in the trauma registry. I would still recommend obtaining the reports for their educational value, especially for those of you who are part of residency training programs.

Related post:

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. J Trauma 73(3): 587-590, 2012.

General

AAST 2011: Autopsy Reports and Performance Improvement

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Autopsy reports have traditionally been used as part of the trauma performance improvement (PI) process. They are typically a tool to help determine preventability of death in cases where the etiology is not clear. Deaths that occur immediately prior to arrival or in the ED are typically those in which most questions arise.

The American College of Surgeons Trauma Verification Program includes a question on what percentage of deaths at a trauma center undergo autopsy. Low numbers are usually discussed further, and strategies for improving them are considered. But are autopsies really that helpful?

A total of 434 trauma fatalities in one state over a one year period were reviewed by a multidisciplinary committee and preventability of death was determined. Changes in preventability and diagnosis were noted after autopsy results were available. The autopsy rate was 83% for prehospital deaths and 37% for in-hospital deaths. Only 69% were complete autopsies; the remainder were limited internal or external only exams.

Addition of autopsy information changed the preventability determination in 2 prehospital deaths and on in-hospital death (1%). In contrast to this number, it changed the cause of death in about 40% of cases, mostly in the prehospital deaths.

Bottom line: From a purely performance improvement standpoint, autopsy does not appear to add much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. I would still recommend obtaining the reports for their educational value, especially for those of you who are part of training programs.

Reference: Dead men tell no tales: analysis of the utility of autopsy reports in trauma system performance improvement activities. AAST 2011 Annual Meeting, Paper 63.