Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review.

BACKGROUND: The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods. METHODS: A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care. RESULTS: We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital's report system. CONCLUSIONS: Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods

Pediatric hypothermic submersion incident – should we do chest compressions on a beating heart?

Background: Drowning is the third leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. To decide how to treat these patients prehospitally could be challenging in certain situations when uncertain about the adequacy of the patent’s circulation. Methods/case report: We describe a 2 year old boy surviving a 15 min hypothermic submersion in a cold river. In spite of the presence of some vital signs, we decided to do full cardiopulmonary resuscitation to the hospital. The main reason was that we were uncertain about the adequacy of the spontaneous circulation, and the transport to hospital was fairly long. The patient suffered no obvious harm and the outcome was good. Discussion: What is regarded as adequate circulation when accidentally hypothermic between 24 and 250 C? A weak pulse was felt in the femoral artery with a rate of about 40–50 per minute. There were shallow, but regular respiration, and point of care ultrasound revealed a slightly dilated left ventricle and weak, but organised cardiac contractions. Despite these findings a decision was made to continue ventilations and chest compressions during helicopter transport to the University hospital. Conclusion: In an accidentally hypothermic pediatric submersion incident we decided to do full cardiopulmonary resuscitation to the hospital despite there were signs of circulation. We did no harm to the patient. Future guideline revisions should try to clarify how to handle situations with severly accidentally hypothermic patients like this, so the good outcome that is often seen in these patients could be even bette