Medical examiner autopsy reports have traditionally been used as part of the trauma performance improvement process. They are valuable a tool to help determine preventability of death and improve coding accuracy 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 preview questionnaire (PRQ) question requesting the percentage of deaths that undergo autopsy. Low numbers usually prompt the reviewers to discuss the obstacles to obtaining reports. But are autopsies really that helpful?
There are several ways in which autopsies might be helpful:
- Understanding what happened to your patient (education)
- Determining mortality classification (anticipated vs unanticipated)
- Ensuring accurate registry coding
First, let’s look at what trauma medical directors and medical examiners think about this issue. A survey-type study was performed which queried coroners and TMDs across the state of Ohio about what they thought of the benefits and challenges of autopsy. The TMDs indicated that the autopsy advanced medical knowledge 63% of the time vs only about 40% for the coroners. The TMDs reported that they actually used the autopsy results 91% of the time vs only 15% by coroners. Both reported that funding and personnel limitations were an issue in performing autopsies. Interestingly, 25% of coroners agreed with the statement “I do not feel that trauma-related autopsies are necessary.”
So, what about the importance of autopsy data for the trauma registry? A study from New York Presbyterian Queens hospital looked at the impact of autopsy information on ISS scoring of patients dying at the hospital within 48 hours of arrival. Overall, the average ISS of these patients was 13, but after autopsy data was included, it increased dramatically to 49! Patients who died shortly after arrival had an ISS of only 7, but this increased to 50 with addition of the autopsy data. Patients dying later but within 48 hours saw the ISS increase from 23 to 39. So autopsy information was very important for calculating ISS, especially in the “died in ED” patients.
Finally, is autopsy data useful for mortality determinations? 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
From a purely performance improvement standpoint, autopsy rarely adds much to determining preventability of death. It may modify the cause of death, which could be of interest to law enforcement personnel. But it definitely improving ISS accuracy, which is important for probability of survival calculations and TQIP benchmarking. I would still recommend obtaining the reports for their educational value as well, especially for those of you who are part of residency training programs.
Here are some strategies for improving your access to autopsy reports:
- Develop a relationship with your medical examiner. They work in solitude with their techs and a few support personnel. Show an interest in what they do.
- Point out interesting cases that you are sending to them. Have your trauma medical director call and provide some background about the case, and in the case of patients who went to the OR, describe the operative findings. Have the TMD specifically request the autopsy. Sometimes this can make the difference between a full autopsy and an external exam only.
- Remember that the medical examiner offices are typically funded by the county, and not very richly. Call the office and see if there is any way you can help. Some trauma centers have “gifted” reams of paper or sent tokens of appreciation (use your imagination) to get paper copies of autopsy reports.
- Be selective regarding which reports you request. Some trauma deaths have fairly obvious etiologies. An elderly fall with massive subdural hematoma, for example. An autopsy is not going to add much meaningful information. Save your requests for those you are really curious about, and enlist your TMD to call up the ME and chat about it.
- Perceived value of trauma autopsy among trauma medical directors and coroners. Injury 39(9):1075-81, 2008.
- Influence of Autopsy Reports on Trauma Registry Accuracy. J Tra Nurs 26(2):93-98, 2019
- 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.