Montana Trauma System 2009 Trauma Performance Improvement and Peer Review Internet Resources EMS & Trauma Systems http://www.dphhs.mt.gov/ems/ • American College of Surgeons Trauma Program http://www.facs.org/trauma/index.html • ACS Trauma Wikipedia http://www.socialtext.net/acs-demo-wiki/index.cgi • Eastern Association of Trauma (EAST) Trauma Practice Guidelines http://east.org/tpg.asp • National Guideline Clearinghouse http://www.guideline.gov/ • Society of Trauma Nurses http://www.traumanurses.org Patient Safety Patient Safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery. JC 2008 ACS COT Blue Book 2007 Goals • Identify care processes that can be linked to complications i.e. best practices to prevent or treat complications to minimize impact. • Trauma, hospital and regional integration of PI. • Develop techniques using evidence-based guidelines as tools for monitoring care processes and outcomes and for providing corrective action plans. • Reduce the variability in trauma care processes, outcomes and cost across trauma centers.
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Montana Trauma System 2009
Trauma Performance Improvement and Peer Review
Internet Resources
EMS & Trauma Systems http://www.dphhs.mt.gov/ems/
• American College of Surgeons Trauma Program http://www.facs.org/trauma/index.html
• ACS Trauma Wikipedia http://www.socialtext.net/acs-demo-wiki/index.cgi
• Eastern Association of Trauma (EAST) Trauma Practice Guidelines http://east.org/tpg.asp
• National Guideline Clearinghouse http://www.guideline.gov/
• Society of Trauma Nurses http://www.traumanurses.org
Patient Safety
Patient Safety is defined as the avoidance and prevention of patient injuries or adverse events resulting
from the processes of health care delivery. JC 2008
ACS COT Blue Book 2007 Goals
• Identify care processes that can be linked to complications i.e. best practices to prevent or treat
complications to minimize impact.
• Trauma, hospital and regional integration of PI.
• Develop techniques using evidence-based guidelines as tools for monitoring care processes and
outcomes and for providing corrective action plans.
• Reduce the variability in trauma care processes, outcomes and cost across trauma centers.
• Develop means to identify best practices in trauma centers with excellent performance and
disseminate these best practices to all facilities.
Performance Improvement
• Multidisciplinary efforts to measure, evaluate, and improve the process of care and its outcome.
• Evaluate the overall care process to see whether it minimizes risk of harm related to the care
process itself.
• A key objective of PI is to reduce inappropriate variation in care and to improve patient safety.
Trauma centers at all levels must demonstrate a clearly defined PI program for the trauma
population that should be coordinated with the hospital-wide program (CD 16-1).
• Continuous cycle of monitoring, assessment, and management.
– Because it crosses many specialty lines, the trauma program must be empowered to
address issues that involve multiple disciplines (CD 16-8).
• Well-defined organizational structure
– Approved by the hospital governing body as part of its commitment to optimal care of
injured patients. This commitment must include adequate administrative support and
defined lines of authority that ensure comprehensive evaluation of all aspects of trauma
care (CD 16-9).
• Appropriate, objectively defined standards to determine quality of care
• Definitions of outcomes derived from relevant standards where available
ACS Performance Improvement and Patient Safety Reference Manual
• Current health care imperatives emphasize doing more with less and doing it better and faster.
• Trauma care should be efficacious, safe, and cost-effective.
• Although this may be difficult to translate to the care of some trauma patients, an evidence-
based rather than an empiric approach presents more meaningful criteria against which our
trauma care can be measured.
• A standardized approach to recurring care issues minimize unnecessary variation, allow better
outcome assessment, and makes changes in care easier to implement and more uniform.
• Coordination of the trauma PI program into the hospital-wide program offers a reduction in
labor while producing more impact on quality.
Staff Responsible for the Trauma PI Program
• The Trauma Medical Director and the Trauma Coordinator maintain the Trauma PI process with
data support from the Trauma Registrar in RTC and ATH at a minimum.
• Trauma Medical Director
– Monitors the trauma PI process
– Responsible for chairing the Trauma PI Committee and for initial review of all physician-
related issues, including all deaths and screened complications
– Responsible for Performance Improvement activity relative to medical providers, as well
as associated remedial action and may delegate related PI review
• Trauma Coordinator
– Responsible for identification of issues and their initial validation
– Responsible for maintenance of the trauma PI database/files and protection of their
confidentiality
– Responsible for facilitating data trends and analysis
– Coordinates monitoring of protocols and guidelines
• Trauma Registrar
– Assists the Trauma Coordinator in trauma PI activities
– Interfaces with medical director and coordinator to assist with identification of issues
using registry filters
– Compiles reports to support the PI process.
• Representatives from other hospital departments and the hospital PI Department
– Participate to ensure multidisciplinary collaboration and coordination with the hospital
PI processes by practicing a multi-disciplinary and multi-departmental approach to
reviewing the quality of patient care across all departments and divisions
Methods of identifying PI issues
• Staff reporting of isolated and cumulative system, process or clinical care quality issues
• All trauma deaths are automatic reviews
• Establishment and monitoring of quality indicators for all trauma patients seen at the hospital
• Periodic focused reviews of various processes and care related issues (i.e. specific complications,
documentation, adherence to care guidelines, etc.)
• Issues identified from an outside agency’s PI process review
Evidence-Based Medicine
• A method of patient care, decision making, and teaching that integrates high-quality research
evidence with pathophysiologic reasoning, experience, and patient preference.
• Utilizing validated methodology for clinical decision making.
• Base clinical decisions on the best available evidence.
• Evidence-based guidelines for institutional protocols or pathways can enhance the buy-in and
compliance of the team.
• Used to develop guidelines and protocols that may be used as the basis for quality indicators
(performance measures).
– A missed or delayed odontoid fracture diagnosis may reflect failure to perform a CT scan
in a patient with an inadequate standard odontoid view.
– This oversight is in noncompliance with an institutional protocol using the evidence-
based cervical spine clearance guideline published by the Eastern Association for the
Surgery of Trauma.
– Corrective action plans, such as education, reinforcement of the protocol, or a revised
protocol, may be indicated.
Outcome
• Results of the care given from the perspective of patient, providers and society.
• Standard outcome measures
• Parameters such as pain control, team morale, community support, or reduction in gunshot
wounds, are examples of outcomes that a trauma program may choose to measure and
improve.
Outcome Measures
• Care processes should be evaluated to determine if they are adequate to achieve the desired
outcome.
• Ineffective processes should be identified, revised, and reevaluated to determine if revisions are
effective.
– Mortality
– Morbidity (complications)
– Length of stay—intensive care unit and total
– Patient safety (absence of harm during care process)
– Cost
– Quality of life
– Patient satisfaction
System Related
• An event or complication not specifically related to a provider or disease.
• Used in the context of a system-related complication or morbidity rather than a provider-related
or disease-related morbidity and usually detected by monitoring process measures.
• For example, a delay in surgeon response to a trauma resuscitation that is attributed to a
system-wide pager dysfunction or an incorrect call schedule may be found to be system-related
rather than disease- or provider-related.
• Such an event may be reviewed by the trauma multidisciplinary committee, usually with a
suggested action plan to prevent a recurrence.
Process Issue
• Elements of care that relate primarily to the system or structure in which the care is delivered.
• Examples include ED triage, blood transport to the ED or surgery, patient transport to CT scan,
equipment available where/when needed, etc.
• Even if outcome has been positive, measuring the process can still be valuable to highlight why
things went well and to look for opportunities to further improve efficiency.
Process Measures
• The following categories of process variables require defined criteria (expectations), which can be
determined from consensus, facility guidelines, or, ideally, nationally derived, evidence-based
guidelines. Some require peer review for determination.
• It is practical to monitor several rather than all of the following examples:
• Compliance with guidelines, protocols, and pathways Guidelines, protocols, and pathways, particularly when evidence-based, can provide parameters to measure performance. In other words, do you do what you say you do?
• Appropriateness of prehospital and emergency department triage Some trauma programs have a tiered-trauma response, and measuring its effectiveness can be useful. Since there are no evidence-based national guidelines, each institution can set its own parameters of acceptability.
• Delay in assessment, diagnosis, technique, or treatment These are standard provider-related quality indicators, requiring subjective determination, usually by peer review.
• Error in judgment, communication, or treatment These are standard provider-related quality indicators, requiring subjective determination, usually by peer review.
• Appropriateness and legibility of documentation
• Timeliness and availability of X-ray reports
• Timely participation of subspecialists Timely participation of neurosurgeons, orthopaedic surgeons, and so on, can vary tremendously. Incorporating institution-specific guidelines with subsequent measurement of compliance can be a powerful tool in improving care. Problems are usually unrelated to the behavior of the subspecialists and are more frequently caused by logistic and communication barriers. Correcting these problems through enhanced institutional resources can be facilitated by incorporating these parameters into the hospital PI program.
• Availability of operating room—acute and subacute Operating room be immediately available for the trauma patient. Is recommended for RTC and ATH. An additional quality indicator more difficult to measure is availability of the operating room for follow-up procedures, like orthopaedic fixation and wound debridement. The ability of specialists to work collaboratively to avoid unnecessary OR trips is also a quality measure.
• Timeliness of rehabilitation Rehab planning should begin soon after admission for most trauma patients. Institutional guidelines can be set though protocols and guidelines. The effectiveness of these tools can be measured as quality indicators.
• Professional behavior The behavior of the medical providers involved in trauma care can set the tone for the entire PI effort.
• Availability of family services Are personnel assigned to meet the family of the arriving trauma patient? This initial encounter can be very important to the rapport that is developed with the trauma team. Is there a process to inform the ICU patient's family, and how effective is it? Periodic surveys of patients' families can be useful.
• Insurance carrier denials The percentage of insurance carrier denials can be a measure of the effectiveness of care documentation. The fiscal viability of the trauma program is improved by obviating the denials through PI measures, such as improved documentation, timely testing and procedures, and so on. This is a potentially fruitful area, offering trauma programs the chance to lead the way for other services in the hospital.
• Admission of trauma patient to nontrauma service
Quality Indicators
Identify key components of quality trauma care
Examples:
• Missing EMS Report
• Glasgow Coma Scale <8, no endotracheal tube or surgical airway
• No laparotomy <1 hour, with abdominal injuries, and systolic blood pressure <90
• Laparotomy after 4 hours
• Craniotomy after 4 hours, with epidural or subdural hematoma, excluding intracranial pressure
monitoring
• Initial treatment >8 hours of open tibia fracture, excluding low-velocity gunshot wound
• Abdominal, thoracic, vascular, or cranial surgery after 24 hours