Analysis Of Annual Variation And The Characteristics Of Mortality And Discharge Against Medical Advice In Trauma Patients Admitted To ICU

Objective:By observing the annual variation tendency of the mortality and discharge against medical advice (DAMA) rate of major trauma patients admitted to an emergency ICU and analyzing the effect of DAMA on therapeutic results, in order to improve the quality of trauma care.Methods:A retrospective analysis was performed on major trauma patients who died or discharged against medical advice in the emergency ICU of a tertiary teaching hospital from2003to2011. These variations included demographic data, injury characteristics and the situation of the treatment. These patients with DAMA were classified as dead, dying, deterioration or improvement according to their situation at discharge. The dead and dying discharged patients were categorized as total death group, the total discharged group including deterioration and improvement. The nine years were divided into three periods (2003to2005,2006to2008and2009-2011).The annual variation of mortality and DAMA were analyzed during those9years. These parameters were also compared in three diverse periods.Results:1)3343major trauma patients were admitted into the emergency ICU from2003to2011.452patients were recruited in the study, in which the total mortality was6.9%(135patients died in the hospital, and96patients were dying at discharge). The ratio of DAMA was6.6%(175cases deteriorated and46cases improved).2) Of those dead and discharged patients,75.7%were male, with a mean age of49±16years. The main causes included traffic injuries (65%) and high fall injury (21.5%). Of them, the majorities were farmers (53.8%) and works (19%). The median ICU length of stay was5(2,11) days. The median ISS, APACHEII and GCS were29(22,35),19(13,24)and5(3,9) respectively. The most common causes of deaths were severely traumatic brain injury (63.7%), multiple organ failure (23.6%) and hemorrhagic shock (12.7%). Compared to death, patients of deterioration at discharge were more older, with lower APACHEII, rate of mechanical ventilation and transfusion, higher GCS. There were statistically significant differences for these parameters.3) From2003to2011, it was significantly decreased in the annual rate of in-hospital death, dying at discharge, and total death(χ2=17.937, P=0.022; χ2=31.589, P<0.001;χ2=34.856, P<0.001). Meanwhile, there was a significant increase in the rate of deterioration at discharge (χ2=15.305, P=0.053). During three periods of2003 to2005,2006to2008and2009to2011, number of patients admitted into the emergency ICU was687,1143, and1513respectively. The age and APACHEII of patients in total death group, deterioration at discharge group and death plus deterioration at discharge group were gradually higher with ongoing three periods. Comparatively, the GCS of them got lower. The mortality was significantly decreased from11.1%to4.6%(χ2=31.174, P<0.001), and the rate of deterioration at discharge was continuously increased from2.8%to6.4%(χ2=12.203, P=0.002). The rate of death plus deterioration at discharge or DAWA were declined from13.8%to11%(χ2=4.09, P=0.129),from16.3%to12.2%,χ2=6.955, P=0.031) respectively.Conclusion:From2003to2011, the quality of trauma care in this EICU was obviously improved. The ratio of DAMA was increased, especially in group of deterioration at discharge with more aged patients. DAMA affected the accurate assessment of trauma care and should be paid more attention for improvement of critical care.