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June 2002
Volume 66 |
Number 6
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| Does Anesthetic
Care for Trauma Present Increased Risk for Patient Injury
and Professional Liability? A Closed Claims Analysis |
Sam R. Sharar, M.D.
Committee on Critical Care Medicine and Trauma Medicine
The astounding frequency of traumatic injury in the United States
– 59 million persons (one in four) injured annually, 36 million
emergency room visits, 2.6 million hospital discharges and 145,000
deaths – explains the regularity with which many anesthesiologists
encounter such cases. As a result, "trauma anesthesia"
is a somewhat transparent subspecialty of our practice in that
to varying degrees, all physician providers of perioperative anesthetic
care find themselves anesthetizing an acutely injured trauma victim.
Nonetheless, the distribution of trauma care among hospitals is
neither random nor equal due to the preferential use of "designated"
trauma centers, geographic maldistribution of hospitals and/or
administrative preference to transfer trauma patients to other
hospitals for economic reasons.1 Likewise, the
distribution of trauma care among anesthesiologists is unequal
due to these hospital factors but also as a result of personal
aversions to trauma care: it occurs at inconvenient times (nights
and weekends), carries a low reimbursement rate (due to the high
frequency of uninsured victims), presents a high-stress environment,
results in unpredictable and often poor patient outcomes and exposes
providers to increased professional liability risk. The validity
of these arguments is variable, however, ranging from confirmed
(low reimbursement rates for trauma care2) to
virtually unknown (anesthetic outcomes and professional liability
risk).
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Frequency (in percent) of trauma claims compared
to nontrauma claims by patient sex (male), emergency nature
of case and critical illness (ASA physical status 3-5).
Values for trauma claims exceed those for nontrauma cases
in all categories (p<0.01).
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In order to specifically assess the patient injury and professional
liability risks of trauma anesthesia care relative to elective
anesthesia care, we examined the ASA Closed Claims Project database
between 1987 (the year after ASA "Standards for Basic Anesthetic
Monitoring" were enacted) and 1999. The database consists
of standardized summary data on closed anesthesia malpractice
claims collected from 35 professional liability carriers that
insure approximately half of the practicing anesthesiologists
in the United States and is described elsewhere in detail.3
All claims for trauma-related anesthetic care (defined as care
provided within three days of acute injury for surgical treatment
of blunt or penetrating trauma, burns, drowning or environmental
injury) were reviewed to identify patterns of causation, injury,
standard of care and liability. Findings were then compared to
those for nontrauma claims occurring during the same period.
Of the 1,814 claims in the database for the time period selected,
87 (4.8 percent) involved trauma anesthesia care. Consistent with
the national demographic pattern of traumatic injuries, the majority
of claims involved men (64 percent compared to 39 percent for
nontrauma claims, p<0.01) [Figure 1]. Also
consistent with the concept that traumatic injuries frequently
require urgent and nondeferrable operative management, the majority
of trauma claims (72 percent) involved emergency anesthesia and
surgery, compared to only 18 percent for nontrauma claims (p<0.01).
The high acuity of anatomic and physiologic derangement in trauma
patients was demonstrated by the high frequency of abnormal ASA
physical status (51 percent of trauma claims were labeled ASA
class 3-5 compared to 34 percent for nontrauma claims, p<0.01).
Outcome measures in the two study groups are summarized in Table
1. Significant increases were identified in the group of trauma
claims compared to nontrauma claims for two outcomes: death (40.3
percent versus 23.4 percent, p<0.01) and median payment ($225,000
versus $95,000, p<0.01). A trend toward an increased rate of brain
damage was observed in the trauma group, although it was not statistically
significant (16.1 percent versus 10 percent, p=0.07). There was
no difference between trauma and nontrauma claims in the frequency
of payment for malpractice claims (44.8 percent versus 47.1 percent),
and somewhat surprisingly, there also were no differences in the
proportion of claims for aspiration (2.6 percent versus 4.3 percent),
awareness of intraoperative events (0 percent versus 2.4 percent)
or difficult intubation (10.3 percent versus 9 percent). Thus,
within the population of patients represented in the ASA Closed
Claims Project database, trauma claims are associated with greater
severity of injury (death and possibly brain damage) and also
result in a higher median claim payment than nontrauma claims
[Table 1].
Two additional endpoints of our analysis were the appropriateness
of anesthetic care and the adequacy of anesthetic record-keeping,
as judged by the anesthesiologist reviewers [Table
1]. These endpoints were chosen to indirectly explore the
issue of whether providing urgent or emergent care in a critically
ill patient at unpredictable times affects anesthetic decision-making
and/or documentation. We found similar frequencies in both trauma
and nontrauma claims for the frequency with which an appropriate
standard of care was met (50.6 percent versus 54.3 percent) and
the frequency of adequate anesthetic record-keeping (51.7 percent
versus 52.6 percent). It appears that within this select population,
trauma care does not impose additional impediments to anesthetic
decision-making or documentation of care over what already exists
for nontrauma care.
As with all studies based on the ASA Closed Claims database,
these results must be interpreted carefully due to inherent limitations
in the database. Numerical estimates of risk cannot be determined
due to the absence of denominator data (i.e., total number of
anesthetics provided) and the fact that not all anesthesia-related
injuries result in a malpractice claim. In addition, data collection
is retrospective and nonrandom. Nonetheless, we are able to draw
several conclusions about patient injuries and professional liability
from our analysis. First, these data suggest that, compared to
nontrauma claims, trauma anesthesia claims involve more emergent
patients, more critically ill patients and result in poor outcomes
more frequently. Considering the urgency, medical acuity and likely
outcome of caring for acutely injured patients, trauma anesthesia
does often present a high-stress environment for providers. Second,
although the frequency of claims payment is similar in both trauma
and nontrauma claims, the median payment is higher for trauma
claims. The reasons for this cannot be determined from our analysis
but may include younger age or more severe injury in trauma claims.
Third, in contrast to conventional wisdom that anesthetic complications
of aspiration, difficult intubation and awareness of intraoperative
events are more likely in trauma patients, there was no increase
in claims for these complications in the trauma group compared
to the nontrauma group. For example, we observed no trauma claims
for awareness of intraoperative events despite reports that in
the select population of hypotensive trauma patients the incidence
of this complication may be as high as 43 percent.4
These observations may reflect limitations of the database in
that the true frequency of these complications in trauma patients
cannot be calculated from closed claims data.
In summary, our review of ASA Closed Claims data reveals that
trauma claims involve more emergent and more severely ill patients
and result in larger claim payments than do nontrauma claims.
These observations should be emphasized with regard to education,
training, administration and reimbursement for trauma anesthesia
care during the development and implementation of local and regional
trauma care services.
References:
1. Nathens AB, Maier RV, Copass MK, Jurkovich
GJ. Payer status: The unspoken triage criterion. J Trauma.
2001; 50:776-783.
2. Selzer D, Gomez G, Jacobson L, et al. Public
hospital-based level I trauma centers: Financial survival in the
new millennium. J Trauma. 2001; 51:301-307.
3. Cheney FW. The American Society of Anesthesiologists
Closed Claims Project: What have we learned, how has it affected
practice and how will it affect our practice in the future? Anesthesiology.
1999; 91:552-556.
4. Bogetz MS, Katz JA. Recall of surgery for major
trauma. Anesthesiology. 1984; 61:6-9.
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Sam
R. Sharar, M.D., is Associate Professor, Department of Anesthesiology,
University of Washington School of Medicine, Harborview Medical
Center and Children's Hospital and Regional Medical Center,
Seattle, Washington. |
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