References and Abstracts

1. Unique Identifier 98373864
Author Blosser SA; Zimmerman HE; Stauffer JL
Institution Department of Surgery, Pennsylvania State University, The M.S. Hershey Medical Center, Hershey 17033-0850, USA.
Title Do autopsies of critically ill patients reveal important findings that were clinically undetected? [see comments]
Source Crit Care Med 1998 Aug;26(8): p1332-6
ISSN 0090-3493

OBJECTIVE: To determine if autopsies performed on patients who die in the medical intensive care unit (ICU) provide clinically important new information.
DESIGN: Retrospective review.
: A 16-bed medical-coronary ICU.
: Patients who underwent autopsy during a 1-yr period.
: Pre mortem diagnoses were determined from the medical record. Autopsy results were obtained from the final pathology report. A panel of three physicians with certification of added qualifications in critical care medicine reviewed the findings.
MEASUREMENTS AND MAIN RESULTS: These questions were asked: a) Is the primary clinical diagnosis confirmed? b) Are the clinical and pathologic causes of death the same? c) Are new active diagnoses revealed? and d) If the new findings had been known before death, would the clinical management have differed? Forty-one autopsies (31% of deaths) were done that showed: a) the same primary clinical diagnosis and post mortem diagnosis in 34 (83%) patients; b) the same clinical and pathologic cause of death in 27 (66%) patients; c) new active diagnoses in 37 (90%) patients; and d) findings that would have changed medical ICU therapy had the findings been known in 11 (27%) patients.
CONCLUSIONS: Although the primary clinical diagnosis was accurate in most cases before death, the cause of death was frequently unknown. Almost all autopsies demonstrated new diagnoses, and knowledge of these new findings would have changed medical ICU therapy in many cases. In the critical care setting, autopsies continue to provide information that could be important for education and quality patient care.
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2. Unique Identifier 99173348
Author Mort TC; Yeston NS
Institution Department of Anesthesiology, Hartford Hospital, CT 06102-5037, USA.
Title The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit [see comments]
Source Crit Care Med 1999 Feb;27(2): p299-303
ISSN 0090-3493

OBJECTIVE: To evaluate pre- and post mortem diagnoses and determine their relationship and the discrepancy rate.
DESIGN: Retrospective, descriptive chart review.
SETTING: A 36-bed surgical intensive care unit (ICU) of an academic, tertiary care center.
PATIENTS: 149 adults who died in the ICU and had an post mortem examination. INTERVENTIONS: Review of the medical record for the ICU course, hospital discharge/death summary, major and minor clinical diagnoses, and the cause of death were directly compared with the major and minor diagnoses and cause(s) of death determined by post mortem examination.
MEASUREMENTS AND MAIN RESULTS: Major and minor clinical diagnoses were categorized by the Goldman method and compared with post mortem findings to determine the discrepancy rate. Patients were categorized by the primary surgical service that provided medical and surgical care. Sixty-one (41%) patients had discrepancies uncovered at post mortem examination, of which 20 had two discrepancies. Twenty-three percent of the 149 patients had errors categorized as major and 18% as minor. Overall, 85% of the major errors were undiagnosed infectious processes. Complete agreement between the pre and post mortem diagnoses was present in 58% and varied with the surgical population: trauma group (86%) and cardiac surgery (69%) vs. the transplantation group (17%). Those with longer lengths of stay in the ICU were more likely to develop and, subsequently, have a major error discovered post mortem. Conversely, those who died early (<48 hrs), were less likely to have an undiagnosed disease at post mortem examination and, thus, more likely to have complete agreement between pre and post mortem findings.
CONCLUSIONS: The overall discrepancy rate as well as the infectious discrepancy rate between pre mortem clinical diagnoses and post mortem findings were substantially higher in a surgical ICU compared with a hospital-wide population. The majority of these discrepancies were undiagnosed infections. The length of time spent in the ICU before death appeared to influence the rate of errors uncovered at the post mortem examination, suggesting that a longer ICU course, as well as the particular type of surgical patient population, may increase the chance of developing an infectious process, only to be uncovered at post mortem examination.
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3. Unique Identifier 82145602
Author Goris RJ; Draaisma J
Title Causes of death after blunt trauma.
Source J Trauma 1982 Feb;22(2): p141-6
ISSN 0022-5282

A retrospective analysis was performed of 89 patients, dead of blunt trauma. Not included in the study were patients with only burns, only head injury, or only a femoral neck fracture and patients who died before or within 1 hr of admission. Correlations were sought between time of death, cause of death, and severity of injury. Death occurring more than 7 days postinjury was caused by remote organ failure associated with sepsis in 88% of the cases. The group of patients who died from sepsis did not significantly differ fom the groups dead from other causes as to age or injury severity. The only distinctive feature of this group was a higher average hospital trauma index for 'extremity injury.' Inadequate immobilization of major fractures in the multiple-injured patient could be a factor leading to late death from sepsis.

4. Unique Identifier 86191338
Author Chandrasekar PH; Kruse JA; Mathews MF
Title Nosocomial infection among patients in different types of intensive care units at a city hospital.
Source Crit Care Med 1986 May;14(5): p508-10
ISSN 0090-3493

Available data on the characteristics of infections in different types of ICUs are limited. Between May and July 1984, overall infection rates of patients in the ICUs and in the general wards at the Detroit Receiving Hospital were 19.2% and 9.8%, respectively (p less than .001). Specific infection rates (number of infections/100 admissions in each unit) were 35.2% for surgical unit, 29.8% for burn unit, 13.9% for medical unit, and 6.6% for coronary unit. Of the total number of patients admitted, only 1.9% patients in the coronary unit became infected while 10.9% to 13.6% in the other three units acquired infection. There were more infections per patient in the surgical unit than in the others. Device-related infections involving the urinary and respiratory tracts were the most common. Predominant pathogens isolated in order of frequency were Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Staphylococcus aureus. Death rates among the infected patients were high; of those infected, nine patients (75%) of 12 in the surgical unit and ten (91%) of 11 in the medical unit died. For those who died, the duration from ICU admission to infection was 2 to 22 days (mean 6.5) and length of survival after becoming infected was 2 to 50 days (mean 22). The mortality rates between the infected and uninfected patients in the medical, surgical, and burn units were significantly different (p less than .0005). Awareness of patterns for nosocomial infection in different ICUs is of value in the adoption of appropriate infection control policies within each unit.

5. Unique Identifier 93136938
Author Barendregt WB; de Boer HH; Kubat K
Institution Department of General Surgery, University Hospital of Nijmegen, The Netherlands.
Title Autopsy analysis in surgical patients: a basis for clinical audit.
Source Br J Surg 1992 Dec;79(12): p1297-9
ISSN 0007-1323

An autopsy study was performed to quantify diagnostic fallibility in clinical surgery. Autopsy results in 312 surgical patients were compared with clinical findings. The primary clinical diagnosis was correct in 93 per cent of patients; complications had been correctly diagnosed in 60 per cent and error in treatment was found in 16 per cent. Error in treatment had an adverse impact on the course of disease in 11 per cent of patients. Infective complications such as abdominal sepsis and bronchopneumonia were encountered most often. Sensitivity was low for the clinical diagnosis of pulmonary embolism, bronchopneumonia, myocardial infarction and terminal haemorrhage. Statistical analysis showed that sudden unexpected death is the most obvious condition in which a high yield is expected from a post-mortem examination. Autopsy remains a valuable means of quality control in clinical surgery and could be a basis for surgical audit.

6. Unique Identifier 87254647
Author Battle RM; Pathak D; Humble CG; Key CR; Vanatta PR; Hill RB; Anderson RE
Title Factors influencing discrepancies between premortem and postmortem diagnoses.
Source JAMA 1987 Jul 17;258(3): p339-44
ISSN 0098-7484

A study of 2067 autopsies collected from 32 university and community hospitals of various sizes located throughout the United States showed the rate of discrepancies between premortem and postmortem diagnoses to be influenced by the type and size of hospital, the age and sex of the patient, and the disease responsible for the patient's death. Of equivocal or no influence were the length of the terminal hospitalization, the degree of clinical involvement in the case of the person responsible for establishing the discrepancy level, and the autopsy rate, at least as it applies to community hospitals.

7. Unique Identifier 96197561
Author Goldstein B; Metlay L; Cox C; Rubenstein JS
Institution Division of Critical Care, Oregon Health Sciences University, Portland, USA.
Title Association of pre mortem diagnosis and autopsy findings in pediatric intensive care unit versus emergency department versus ward patients.
Source Crit Care Med 1996 Apr;24(4): p683-6
ISSN 0090-3493

OBJECTIVE: As part of the overall quality assurance program for the Department of Pediatrics, we determined whether there were differences in the rates of unexpected autopsy findings between pediatric intensive care unit (ICU), emergency department, and ward patients. DESIGN: Prospective, descriptive study.
SETTING: Tertiary care children's hospital. PATIENTS: Pediatric deaths (n = 212).
MEASUREMENTS AND MAIN RESULTS: Autopsies were obtained more frequently in emergency department patients (27/29 [93%]) compared with pediatric ICU (88/121 [73%] and ward (42/62 [68%]) patients (p = .03). The medical examiner's cases were more frequently from emergency department patients (22/27 [81%]) compared with pediatric ICU (39/88 [44%]) or ward (11/42 [26%]) patients (p < .001). We found unexpected autopsy findings in 19 (12%) of 157 patients. There were no unexpected findings from the medical examiner's cases. The most common unexpected findings were unidentified infections (n = 7 [three fungal, three viral, and one nonspecific]) and unrecognized cardiac malformations (n = 4). Unexpected findings occurred more frequently in pediatric ICU patients (16/88 [18%]) vs. emergency department (2/27 [7%]) or ward (1/42 [2%]) patients (p = .03). The occurrence rates of major unexpected findings (Class I and II) in pediatric ICU (7/79 [9%]), emergency department (2/27 [7%]), and ward (1/42 [2%]) patients were similar (p = .4). There were two Goldman's Class I unexpected findings in the pediatric ICU and emergency department patients, and one Goldman's Class I unexpected finding in the ward patients. CONCLUSIONS: Autopsies were performed more frequently in emergency department patients. Class I through IV unexpected findings occurred more frequently in pediatric ICU patients compared with emergency department or ward patients. Autopsy examinations are an especially valuable diagnostic tool for pediatric ICU patients and physicians.
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8. Unique Identifier 75029421
Author Britton M
Title Diagnostic errors discovered at autopsy.
Source Acta Med Scand 1974 Sep;196(3): p203-10
ISSN 0001-6101

9. Unique Identifier 20372433
Author Juvin P; Teissiere F; Brion F; Desmonts JM; Durigon M
Institution Service d'Anesthesie et de Reanimation, Hopital Bichat, Paris, France. .
Title Postoperative death and malpractice suits: is autopsy useful?
Source Anesth Analg 2000 Aug;91(2): p344-6
ISSN 0003-2999

This report demonstrates the extremely high yield of autopsies performed in the case of postoperative death with suspicion of malpractice. They frequently identified undetected complications. They could also suggest faulty or negligent practice that would otherwise go unrecognized. This report supports the widespread use of autopsies to investigate perioperative death.

10. Unique Identifier 83167332
Author Goldman L; Sayson R; Robbins S; Cohn LH; Bettmann M; Weisberg M
Title The value of the autopsy in three medical eras.
Source N Engl J Med 1983 Apr 28;308(17): p1000-5
ISSN 0028-4793

To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.

11. Unique Identifier 84230522
Author Goldman L
Title Diagnostic advances v the value of the autopsy. 1912-1980.
Source Arch Pathol Lab Med 1984 Jun;108(6): p501-5
ISSN 0363-0153

Between 1912 and 1980, many English language publications analyzed the correlation between clinicians' diagnoses and postmortem examinations. Surprisingly, the percentage of cases with undiagnosed principal underlying diseases or primary causes of death has not diminished during this period. The autopsy's unvarying percentage yield does not indicate a lack of progress, however, since bacterial pneumonia, hepatic cirrhosis, and common tumors were missed routinely in earlier eras but were rarely missed after 1970. Pulmonary embolism remains commonly missed, but the striking recent finding is the emergence of fungal and other systemic infections that were rarely noted in prior eras. Progress in diagnosis and treatment may allow patients to live longer and new or obscure diseases may develop that will often be missed clinically. An appropriately high autopsy rate will be required if medical progress is to continue.

12. Accreditation Council for Graduate Medical Education: Revised essentials of accredited residencies in graduate medical education. Part I, The institutional requirements. In: ACGME Bulletin. Chicago, 1996, p 3

13. American Medical Association: Graduate Medical Education Directory 1995-1996. Chicago, American Medical Association

14. Unique Identifier 92389107
Author Champ C; Tyler X; Andrews PS; Coghill SB
Institution Department of Pathology, Kettering General Hospital, Northamptonshire, U.K.
Title Improve your hospital autopsy rate to 40-50 per cent, a tale of two towns.
Source J Pathol 1992 Apr;166(4): p405-7
ISSN 0022-3417

In the light of medical audit, all pathology departments are scrutinizing their hospital autopsy rate. In most countries, the rate has fallen over the last few decades to between 10 and 20 per cent. However, it is still possible to achieve a much higher rate. We compare two neighbouring District General Hospitals (DGHs): Northampton, with the more usual autopsy rate of 11 per cent, and Kettering, with a higher rate of 40-50 per cent. These hospitals are comparable in almost every way except for the system used to request permission for an autopsy. These differences were evaluated and the following factors were found to be of importance in achieving a high rate: (1) centralization of death certificates within the mortuary and personal contact between the certifying doctor and the relatives within the bereavement room; (2) mortuary pathology technicians are designated as bereavement officers and act as coordinators between relatives, clinicians, and pathologists; and (3) regular clinico-pathological meetings and a positive attitude to autopsies by clinicians.

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