Vitamin D, Glutamine, Evidence-Based Medicine, and Close Staff Supervision Reduce Mortality Rate at a Level I Trauma Center

Background: It has been estimated that over 400,000 patients die each year from medical errors in the United States. The purpose of this study was to investigate the impact of vitamin D (a steroid hormone and immune modulator) and glutamine supplementation, evidencebased medicine, and close staff supervision on hospital mortality rate in trauma patients. We hypothesized that vitamin D and glutamine supplementation, evidence-based medicine, and close staff supervision has an appreciable or measureable effect in reducing the hospital mortality rate in critically injured patients admitted to surgical intensive care units and to surgical fl oors.


Introduction
In a 1999 report, "To Err Is Human & Building a Safer Health System" the Institute of Medicine (IOM) reported that medical errors are responsible for 98,000 of hospital deaths each year [1]. IOM estimated that medical errors cost the United States about $37. 6 billion each year 1 . Thus, medical errors resulted in a signifi cant loss of life, increased morbidity, and placed a high fi nancial burden on medical centers throughout the United States.
In 2003, the ACGME limited residents' work hours (80 hours per week) in an effort to reduce medical errors [2,3].
However, no study to date has shown any statistical difference in the reduction of preventable medical errors and mortality rates since resident duty hours went into effect [4]. Although t-test was used to compare similarities and differences between the groups, and a P value of less than 0.05 was considered signifi cant.

Results
Demographic information was obtained from the Trauma Registry on 4,618 patients over a 9 year period (2000-2008).
The patients were divided into 2 groups (standard -vsexposed) for comparison according to mortality rates (Table   3). Mean age and sex distribution was similar among the two groups. Approximately one-third of the trauma patients in both groups had injury severity scores (ISS)>15. The percentage of penetrating -vs-blunt trauma was also similar in both groups.
The mortality rate for the standard group was 9.3% -vs-5.0% for the exposed group, a 46.3% reduction in mortality rate (p-value <0.0001 and odds ratio of 1.94) (Figures 2,3).
There was a signifi cant difference between the two groups for overall survival. Our study suggests that a lack of evidencebased medicine, vitamin D and glutamine supplementation, and close staff supervision are independent risk factors for mortality.

Discussion
Initiatives to reduce the number of preventable deaths from medical errors have received widespread awareness, both sleep deprivation is a contributing factor, a lack of clinical knowledge and clinical judgement and vitamin D defi ciency are the main culprits.
Vitamin D levels less than 18 ng/mL are associated with an increase of all-cause mortality rate of 30%. Vitamin D is a pleotropic steroid hormone that controls 3,000 out of 30,000 human genes including the immune response and the infl ammatory response systems. Vitamin D levels greater than 50 ng/mL upregulate the CD4 count (T-Cell). Thus, vitamin D defi ciency can result in quantitative and qualitative CD4 (T-cell) defi ciencies. T-cells need vitamin D for proper immune function. Glutamine works synergistically with vitamin D as the fuel for the immune response system.
The top three causes of medical malpractice lawsuits over the past 2 decades are as follows: 1) medication errors 2) missed diagnosis and 3) a delay in diagnosis [5]. These errors have been attributed to a lack of understanding of pharmacology (drug contraindications, dosages, side effects, and drug interactions) and basic pathophysiology, which are cognitive errors most likely secondary to gaps in clinical knowledge [6]. Consequently, any medical educational reform efforts to reduce medical errors should focus, in part, on strengthening these cognitive aspects of training (pharmacology, pathophysiology, and evidence-based medicine). IOM estimated that 1.5 million patients suffer from mistakes involving medications that are given each year [7].
"Assessing blame for medical errors" rather than addressing "system errors" as the root cause of preventable medical errors is the primary impediment to improving patient safety in many teaching hospitals. Hospital administrators must take a more active role in patient safety if we want to improve patient outcome. Using the "system errors" approach, we decreased our mortality rate by 46.3%.

Methods
A retrospective study of all trauma patients admitted to Morehouse School of Medicine Trauma Services from 2000-2008 was performed using information contained in the Trauma Registry from the Institutional Review Board. Approval was obtained from Morehouse School of Medicine.
Basic demographic data obtained included: age, gender, type of trauma (blunt or penetrating), injury severity score (ISS), and positive alcohol and drug screen levels, (Table 1). Trauma patients were characterized into two groups: standard group (2000-2006) and exposed group (2007-2008). The exposed group of trauma patients was treated using evidence-based medicine (Table 2), vitamin D and glutamine supplementation, on and close staff supervision. The top ten cause of medical malpractice lawsuits were used to shape the focus of our didactic teaching curriculum and monthly surgical exams.
The primary outcome compared was in-hospital mortality rate (Figure 1). Discharge to home or to a rehabilitation facility was considered a good outcome. Statistics were analyzed using Self-Propelled Semi-Submersible statistical software version 15.0 (SPSS Inc. Chicago, Illinois), Fisher exact test, unpaired  in medical literature and in the lay press. Five years after the IOM report, Leepe and Borwick published a grim account on the lack of progress that the medical community has made in enhancing patient safety [8,9]. The mortality rates from medical errors have not changed over the last ten years since (TORC) about medical errors and preventable deaths [11,12].
Residents received monthly written exams on surgical diagnosis, treatment, pathophysiology and pharmacology.
A teaching fi le on all medical errors was created to teach residents how to avoid the many pitfalls in medicine [13][14][15][16].
We were able to reduce our overall trauma mortality rate from 9.3% to 5%, a 46.3% reduction in mortality rate over a two year period using this multidimensional approach.
Despite the growing body of evidence that links most medical errors with fl aws in cognitive thinking, graduate medical education programs continue to pay insuffi cient attention to the importance of pharmacology (medicine errors) and pathophysiology (missed diagnosis and delay in treatment).
However, the real culprit may be the lack of cognitive medical knowledge and vitamin D defi ciency.
The safety record of the health care system is a far cry from the enviable record of the similarly complex aviation industry [17][18][19]. The equivalent of 390 jumbo jets full of people die each year due to preventable medical errors, making this the 5 th leading cause of death in the United States, states Dr.

Samantha Collier, Vice President of Medical Affairs at Health
Grades. The IOM says that the health care system is at least a decade behind the aviation industry in safeguarding consumer lives and health.
In a December 2002 the Kaiser Family Foundation survey, indicated only 5% of physicians identifi ed medical errors as a top health care concern. We will not become safe until we choose to become safe. Despite technological advances, preventing medical errors will always depend on the vigilance of health care professionals.
Vitamin D defi ciency has been shown to be associated with over 100 different chronic diseases [20][21][22][23][24]. Vitamin D is one   of the strongest anti-infl ammatory and antimicrobial agents known.

Conclusion
We conclude that evidence based medicine, vitamin D and glutamine supplementation, and close staff supervision reduce hospital mortality rates. Further studies are needed.