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.

Effective PI Program

• Authority and accountability for the program

– 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.

Process Measures

• 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

• Admit by non-surgeon in RTC and ATH

• Trauma death

• Ambulance scene time >20 minutes

• Absent hourly charting

• Transfer after 6 hours in the initial hospital

• Re-intubation within 48 hours of extubation

• Complications

Morbidity

• Any deviation from normal health that may be a result of a complication or may be preexisting

(sometimes called a co-morbidity)

• ARDS is usually a complication, whereas chronic obstructive pulmonary disease is a co-

morbidity.

• Distinction must be made for more accurate risk adjusting and outcome benchmarking.

Disease Related

• An event or complication that is an expected sequela of a disease, illness, or injury.

– Intra-abdominal abscess after damage control laparotomy, despite good surgical

technique and appropriate antibiotics.

– Infectious events - Urinary tract infection after prolonged, but necessary urethral

catheter

– Pulmonary (noninfectious) - ARDS from injury despite best available treatment

– Organ failure (pulmonary, renal, liver) - despite preventative efforts

– Cardiovascular events - Atrial fibrillation after appropriate fluid resuscitation

– Neurologic events - Intracranial hemorrhage during appropriate therapy

– GI events - Ileus after injury, or stress ulcer bleed despite appropriate prophylaxis

– Hematologic events - Anemia after unavoidable blood loss in the field

– Dermatologic events - Skin-sloughing over area of severe contusion; for example, in the

elderly

Co-Morbid Conditions

• Alcoholism

– Ascites

– Esophageal Varices

• Cardiac disease

– Angina within past 1 month

– Congestive heart failure

– Myocardial Infarction within past 6 months

• Respiratory Disease

• Vascular

– Bleeding disorder

– Revascularization/amputation for Peripheral Vascular Disease

– Hypertension requiring medication

• Medication Use

– Chemotherapy for cancer within 30 days or disseminated cancer

– Diabetes mellitus

– Steroid use

• Current smoker

• Dialysis Patient

• Congenital Anomalies

• Functionally dependent health status

• Impaired Sensorium

• Prematurity

• Obesity

• Do Not Resuscitate (DNR)

Complication

• Any event that deviates from an anticipated uneventful recovery from illness or surgery

• Hypothermia and coagulopathy on admission after major trauma are usually not complications,

but consequences of the inciting event.

• Hypothermia or coagulopathy after initial resuscitation may be complications.

Hospital Complications

• Blood

– Base deficit

– Bleeding

– Coagulopathy

– Deep Vein Thrombosis

• Brain

– Coma OR increased ICP

– Stroke/CVA

• Cardiac

– Cardiac arrest with CPR

– Myocardial infarction

• Compartment syndrome

– Abdominal (fascia left open)

– Extremity

• Drug or alcohol withdrawal

• Infection

– Surgical site

– Organ, space

– Systemic sepsis

• Respiratory

– ARDS

– Pneumonia

– Pulmonary embolism

– Unplanned intubation

– Renal failure (acute)

• Skin

– Decubitus ulcer

– Wound disruption

PRIMARY Review

• Concurrent/ Retrospective issue identification

• Trauma Coordinator validation of issue

• Immediate resolution and feedback

• Documented in PI process

• Maybe closed at this level

SECONDARY Review

• Review by Trauma Medical Director and Trauma Coordinator

• Judgment / initial action plan

• Investigation of the issue

• Issue may be closed at this level or referred

• Refer to Multidisciplinary Trauma Committee

• Refer to Peer Review Committee

• Documented in PI process

TERTIARY Review

• Review at a formal committee

– Multidisciplinary Trauma Committee

– Trauma Peer Review

– Regional and Systems PI

• Action

• Judgment

• Document in minutes & PI database

Committee Structure

• Trauma Peer Review

– Clinical concerns

– Provider related

• Multidisciplinary Trauma Committee

– System /Operations

– Process focused

Multidisciplinary Trauma Committee

• There must be a process to address trauma program operational issues (CD 16-15).

• Best accomplished by a multidisciplinary committee that examines trauma-related operations

and includes representatives from all phases of care provided to injured patients.

• Includes physicians, prehospital personnel, nurses, technicians, administrators, and other

ancillary personnel.

• Meet at least quarterly or monthly to review system process and operational performance

issues.

• Documentation (minutes) must reflect the review of operational issues and, when appropriate,

the analysis and proposed corrective actions (CD 16-16).

• This process must identify problems and must demonstrate problem resolutions (loop closure)

(CD 16-17 and CD 16-18).

Trauma Peer Review Committee

• Goals

– Review the performance of the trauma program

– Review the safety of the trauma program

– Provide focused education

– Provide peer review

• Objectives

– Identify and resolve problems

– Trigger new policies/protocols

– Representatives act as conduits to their departments

• These activities can be accomplished in a variety of formats, depending on the volume of trauma

patients.

• Trauma center staff should be familiar with state laws governing peer review. Most peer review

activities are protected from discovery.

• Minutes from peer review activities should be written carefully but document a candid

discussion.

• There must be a peer review committee with participation by the trauma medical director and

representatives from general surgery, orthopaedic surgery, neurosurgery, emergency medicine,

and anesthesia to improve trauma care by reviewing selected deaths, complications, and

significant care issues including "near misses" with the objectives of identification of issues and

appropriate responses (CD 16-19). Trauma Coordinator must attend

• Participation must include attendance by the aforementioned representatives at a minimum 50%

of the peer review committee meetings (CD 16-20).

• Each member of the core group of general surgeons must attend at least 50% of the peer review

committee meetings (CD 16-21).

• In circumstances in which attendance is not mandated, that is, noncore general surgeons, the

trauma medical director must ensure dissemination of information with documentation (CD

16-22 and CD 16-23). (Dissemination of information typically is achieved by attendance at peer

review meetings when an individual’s case is being discussed or by letter.)

• Evidence for appropriate participation and acceptable attendance must be documented in the PI

process (CD 16-24). This meeting is usually held quarterly or monthly based on the needs of the

program.

• All deaths must be systematically reviewed and categorized as preventable, nonpreventable, or

potentially preventable through a peer review process (CD 16-25).

Montana Code Annotated 2009

• 50-16-204. Restrictions on use or publication of information. A utilization review, peer review,

medical ethics review, quality assurance, or quality improvement committee of a health care

facility may use or publish health care information only for the purpose of evaluating matters of

medical care, therapy, and treatment for research and statistical purposes. Neither a committee

nor the members, agents, or employees of a committee shall disclose the name or identity of

any patient whose records have been studied in any report or publication of findings and

conclusions of a committee, but a committee and its members, agents, or employees shall

protect the identity of any patient whose condition or treatment has been studied and may not

disclose or reveal the name of any health care facility patient.

50-16-201. Definitions. As used in this part, the following definitions apply:

(1) (a) "Data" means written reports, notes, or records or oral reports or proceedings created

by or at the request of a utilization review, peer review, medical ethics review, quality

assurance, or quality improvement committee of a health care facility that are used exclusively

in connection with quality assessment or improvement activities, including the professional

training, supervision, or discipline of a medical practitioner by a health care facility.

(b) The term does not include:

(i) incident reports or occurrence reports; or

(ii) health care information that is used in whole or in part to make decisions about an

individual who is the subject of the health care information.

(2) "Health care facility" has the meaning provided in 50-5-101.

(3) (a) "Incident reports" or "occurrence reports" means a written business record of a health

care facility, created in response to an untoward event, such as a patient injury, adverse

outcome, or interventional error, for the purpose of ensuring a prompt evaluation of the event.

(b) The terms do not include any subsequent evaluation of the event in response to an

incident report or occurrence report by a utilization review, peer review, medical ethics review,

quality assurance, or quality improvement committee.

(4) "Medical practitioner" means an individual licensed by the state of Montana to engage in

the practice of medicine, osteopathy, podiatry, optometry, or a nursing specialty described in

37-8-202 or licensed as a physician assistant pursuant to 37-20-203.

Education

• A periodic trauma case review is useful for providing corrective action or disseminating

evidence-based guidelines.

• This activity may be incorporated monthly into existing departmental conferences in low-

volume centers.

• The importance of taking advantage of existing educational conferences cannot be

overemphasized. These are part of many trauma teams’ expected activities and are a rich source

for information exchange.

• Education should be focused on topics for evidence-based guidelines, when possible, to

enhance the PI initiatives.

Documentation of Analysis and Evaluation

• The Trauma QI issues documented on the Trauma Committee Form.

• Include all aspects of the case review including the summary of the clinical care, identified

issues, reference to discussion/minutes from the Trauma PI Committee(s), judgment,

recommendations, actions, and loop closure.

• Assure tracking and documentation of loop closure.

• The form can be placed into the minutes of the Trauma Committee meetings where discusses as

evidence of case review with discussion and recommendations for corrective action.

Referral Process for Investigation or Review

• The cases determined to require further investigation by the first and second level review or a

judgment/rating determination by the Trauma Committee may be referred to the appropriate

hospital department via appointed liaisons, committee or department chairman for review.

• The Trauma Committee and/or the Trauma Medical Director to review the response of the

referral for follow up.

• The Trauma Committee should provide a summary report to the Medical Executive and/or other

appropriate Committee on a regular basis.

TRAUMA PERFORMANCE IMPROVEMENT

Reference Manual

American College of Surgeons

Committee on Trauma

January 2002

Some realities to review:

• Nobody has an ideal trauma program.

• Most programs struggle with PI

• No precise prescription for PI exists.

• The trauma director must lead.

• The effort must be multidisciplinary.

• The trauma PI programs can set the PI tone for the health care organization.

• Adverse outcome does not always indicate bad care.

• The focus should be on opportunities for improvement rather than on problems.

• Most errors are related to system failure.

• Timely collection and analysis of meaningful data are great challenges.

• A solid trauma PI program provides leverage for obtaining needed resources.

• Trauma PI is most effective when integrated with hospital-wide (system-wide) PI.

• The trauma program should be familiar with Joint Commission requirements for PI and current

initiatives for patient safety as promoted by the Institute of Medicine.

• PI will benefit from the advances in information technology.

• Current interest exists in evidence-based, guideline-derived PI.

Nonpreventable

An event or complication that is a sequela of a procedure, disease, illness, or injury for which reasonable

and appropriate preventable steps have been taken.

• Gunshot wound to the head with a GCS of 3 on arrival and subsequent death,

• Pneumonia, deep venous thrombosis (DVT), and so on, in patients who had appropriate

preventative steps taken.

• Most deaths and morbidities fall into this category.

Potentially Preventable

An event or complication that is a sequela of a procedure, disease, illness, or injury that has the

potential to be prevented or substantially ameliorated.

• Iatrogenic pneumothorax or wound dehiscence, wherein alternate techniques or judgments may

have prevented the complication with some certainty.

• Such a choice is always a difficult call and requires determination from experienced physicians.

• An example may be an elderly trauma patient with a severe head injury who develops a fatal

arrhythmia from electrolyte abnormality. The arrhythmia may have been preventable, but it is

unlikely that the death was; therefore, the death is deemed “potentially preventable.”

• A patient suffering a preventable morbidity who subsequently expires after being declared DNR

by family or advanced directive may be determined to be a potentially preventable mortality.

Preventable

An event or complication that is an expected or unexpected sequela of a procedure, disease, illness, or

injury that could have been prevented or substantially ameliorated.

• A patient admitted with abdominal distention and shock who dies from a ruptured spleen two

hours later while waiting for a surgeon.

• Death as a result of a missed epidural hematoma or esophageal intubation may be preventable.

• Preventable mortalities should be very unusual in a mature trauma system.

• A missed fracture resulting from failure to examine the patient may be preventable morbidity.

Action Plan

• Multiple Categories

• I.e. educational, resources, system enhancement

• Potentially move to higher level of authority

• Must be measurable

• Include proof it happened

• Not loop closure

Corrective Action

• Examples:

– Guideline, protocol, or pathway development and revision

– Targeted education (for example, rounds, conferences, journal clubs)

– Enhanced resources, facilities, or communication

– Process improvement team implementation

– Counseling

– Peer review presentations

– Change in provider privileges or credentials

– External review

• Monitoring and evaluation may determine that performance meets or exceeds expectations.

• It may be useful to monitor trends continuously or periodically.

• When a consistent problem or inappropriate variation is identified, corrective actions must be

taken and documented (CD 16-26).

Evaluation

• Measurable

• Potential Re-evaluation

Problem Solved (Loop Closure)

• The word “loop” refers to a cycle of monitoring, finding, fixing, and monitoring again.

• Has corrective action made a difference?

• Is correction complete at level needed?

• Is follow up or intermittent monitoring needed?

• Loop can be closed temporarily with follow up or permanently

Closing the Loop

• PI must demonstrate that a corrective action has the desired effect as determined by continuous

evaluation.

• As the definition of quality is neither exact nor constant, improvement cannot always be

demonstrated with compelling data; however, systematic use of a defined PI process can.

• Although some process loops may never be completely closed, all trauma programs should

demonstrate the continuous pursuit of performance improvement and patient safety.

• Problem: Incorrect choice of antibiotic for abdominal gunshot wound. Solution: Surgeon

apprised of event and provided guideline.

Loop closure: Review of antibiotic utilization in subsequent cases by that surgeon to

demonstrate conversion to use of appropriate antibiotic. Loop closed if compliance

demonstrated. Referral to Peer Review Committee if not.

• Problem: Inconsistent setup of cell saver during ED trauma codes. Solution: Staff apprised of

issue with educational intervention for ED RN leadership and staff. Monitor cell saver practice in

ED during trauma codes.

Loop closure: Document satisfactory resolution.

Peer Review

• MEANINGFUL peer review is difficult, dependent on many variables and can be elusive

Methods can include;

- Providers review each others’ care

- Send cases out for review

- Bring “expert” in for care reviews Three Necessary Functions to Consider

• Multidisciplinary trauma program performance

- Assess & correct trauma program process issues including review of identified QI/PI

• Multidisciplinary case reviews

- Identify issues in all phases of care & all levels of care providers, with potential solutions

for improvement (guideline development/education, etc.)

- Methods for implementation & strategies to monitor for recurrence/effectiveness

• Confidential provider Peer Review

- Process without general committee attendance, MUST have Trauma Coordinator

participation

- Response, appropriateness/timeliness of care, evaluation of care priorities

How to Best Accomplish the Three Necessary Functions?

• Two separate committees? One for confidential Peer Review and another for program

evaluation and case reviews?

• One Committee with some attending excused for Peer Review process?

• Separate case reviews conducted with all players invited?

• Conduct these three processes using methods that work best for your facility, resources and

stakeholders

Our Realities to Review

• Good Trauma PI process takes time

• Trauma PI process is a HUGE leap for all disciplines

• Don’t expect everyone to welcome new approach

• Must integrate w/everything else to be effective

• Truly need a medical provider “champion” to drive effective process

• One approach doesn’t ”fit” all facilities

• If all players aren’t involved, meaningful change will not happen

• Tailor requirements to YOUR resources, your mix of players

• Don’t be afraid to “tweak” it (continuous monitoring, evaluation, review and revision to achieve

effective processes are the core concepts of Performance Improvement)

• This form of PI can be successfully replicated for ALL patient care

What’s truly in it for us? IMPROVED PATIENT CARE!!!